Order-12.

Date-13/07/2015.

Complainant Sri Swapan Kumar Chatterjee by filing this complaint submitted that Mrs. Rama Chatterjee, mother of the complainant since deceased was admitted by the complainant at Sanjeevani, P-48, Khirode Bidya Binode Avenue, Kolkata (Op No.1) on 27.10.2013 for the purpose of undergoing the Hysterotomy Operation by Dr. Polly Chatterjee.

After conducting the said operation on 28.10.2013 by said doctor at the said Nursing Home she was released on 02.11.2013.After the said operation, on 09.12.2013 complainant lodged a claim from Rs. 46,813.68 paisa towards the cost of the said operation along with all original documents and a Schedule of Medical Expenses with the op no.3 Insurance Company under due acknowledgement and the same had been settled at Rs. 19,149/- by the op no.4.

Admittedly at the time of admission of the patient on 27.10.2013 Rs. 5,000/- in cash and on the date of release on 02.11.2013, Rs. 24,431/- through Debit Card aggregating Rs. 29,431/- were paid by the complainant to op no.1.During the period of Hospitalisation from 27.10.2013 to 02.11.2013 no direct payment towards Doctor’s/Consultants charge to anybody was ever made by the complainant and on the cost of medicine & pathological tests were directly borne by the complainant.

Op no.1 supplied many papers to the complainant which inter-alia consist of both unstamped and stamped bills of the op no.1 and a fake money receipt for Rs. 19,700/- of the complainant.That in the stamped bill, it appears a figure of Advance Payment of Rs. 29,431/- and alleged Excess Refund for Rs. 19,700/-.Fact remains that the complainant paid to op no.1 of Rs. 29,431/- as it is claimed towards Hospitalisation Expenses, which includes all doctors’ fees, room rent and other ancillary expenses whatsoever required during the Hospitalisation period and no amount of refund of Rs. 19,700/- had even been received by him from op no.1.

By virtue of letters dated 25.10.2014 and 27.11.2014, complainant requested to op no.1 to supply the break up for computation of Rs. 29,431/-, the copy of signed money receipt of complainant acknowledging the receipt of Rs. 19,700/- as shown in the Bill dated 02.11.2013 of op no.1.Instead of supplying the same, op no.1 sent certain papers on 23.12.2014 which include – a duplicate provisional bill of Rs. 3,500/- of Dr. Kalyan Paul, duplicate provisional bill of Rs. 24,000/- of Dr. Polly Chatterjee, duplicate provisional bill of Rs. 600/- of Dr. Sujay Roy and duplicate provisional Bill of Rs. 6,000/- of Dr. Abhinibesh Chatterjee and the aggregate amount of said doctor’s fees appears to be Rs. 34,700/- which had never been paid by the complainant to said doctors.

That op no.1 earlier supplied the Receipts of doctors’ fees as Receipt dated 03.11.2013 of Dr. Kalyan Kr. Paul for Rs. 3,500/-, Receipt dated 01.11.2013 of Dr. Polly Chatterjee for Rs. 24,000/-, Receipt dated 01.11.2013 of Dr. Abhinibesh Chatterjee for Rs. 7,200/-.So aggregate amount of said doctors’ fees appears to be Rs. 34,700/- and there is discrepancy in the amount of fee claimed by Dr. Abhnibesh Chatterjee.

That in a letter to op no.4 (i.e. TPA) sent on 22.09.2014, the said Hospital op no.1 informed that the bill without seal and stamp was not its final bill.It is mentioned that the said amount of consultant charge for Rs. 34,700/- was included in the bill without seal and stamp of the op no.1 and not in its bill with seal and stamp and thus there was reason to apprehend the adoption of unfair trade practice by the op no.1.After lodging of the claim to Insurance Co., both the op no.2 and the op no. 4 commented that two types of Bills of op no.1 were very confusing and they also commented how the money receipts for doctors’s fees for Rs. 34,700/- had been submitted though the complainant denied payment of the same.The relevant correspondences of the op no.2 and op no.4 in this regard are filed.

On the points of advance payment of Rs. 29,431/- and alleged excess refund of Rs. 19,700/- as cited in stamped bill by op no.1, no documentary evidence could be produced and no reason could ever be established by the op no.1 for its inclusion of said items for settlement of the claim of the complainant.Thus there was deficiency on the part of the op no.1.

There had been long war between the TPA and the complainant ever since submission of said claim on 09.12.2013 through the series of correspondences and upon intervention of the op no.2 after lodging of a complaint to the Grievance Cell of the Insurance Co. by the complainant and said for Rs. 46,813.68 paisa was settled by TPA op no.4 at Rs. 19,149/- by payment of three phases on different dates leaving a residual balance of claim of Rs. 27,113.68 paisa.

It is humbly submitted that there had been deficiency of service on the part of Hospital op no.1 for its inability to furnish the break up for computation of Rs. 29,471/- since paid to it by complainant and its inability to produce the original of the money receipt for Rs. 19,700/- of the complainant acknowledging the receipt of money from them.It is further submitted that there had been adoption of unfair trade practice by Hospital op no.1 for its supplying of two types of doctors’ consultants fee that there had been contradiction and further adoption of unfair trade practice by Hospital op no.1 because of its dubious action and accordingly complainant suffered much for adopting some unfair trade practice, complainant faced several problems and in the above circumstances, complainant prayed for directing the op no.1 to refund Rs. 19,700/- and also for compensation for causing mental pain and agony for adopting unfair trade practice.

Fact remains that in this case there is no allegation against the Insurance Company, but Insurance Company is made a party and Insurance Company by filing this written statement submitted that the claim of the complainant was settled for Rs. 19,149/- and amount of Rs. 27,664/- was disallowed by the complainant by the terms and conditions of the policy and complainant has admitted the fact.

Fact remains that insured has submitted improper Hospital Bill vide Bill No. DB/13-14/02642 dated 02.11.2013 for Rs. 44,431/- which is admitted by the complainant and he advised the complainant to ignore this bill and regarding this matter a mail from the Hospital which is also received and annexed with the written statement. The Doctor fees for Rs. 34,700/- was included in the bill and as per insured view, he has not paid any doctors’ fees.Again insured has submitted Hospital Bill vide same bill no and same date for Rs. 9,731/- where doctor fees are not included in the second Hospital Bill and for doctor fees the insured has submitted a separate money receipt no. 20 for Rs. 3,500/-, receipt No. 578 for Rs. 24,000/- and receipt No. 414 for Rs. 7,200/- respectively aggregating Rs. 34,700/-.The TPA settled the calim on advise of the complainant on the basis of second Hospital Bill duly signed and sealed by Hospital authority.

Op nos. 2 & 3 beg to clarify the deduction amount i.e. Rs. 10,000/- was paid towards doctor’s fee which was directly paid to doctor by the insured, under policy condition note 2 & 3 (b), as per condition of policy note 2 under 2.3 (Note no.2) “No payment shall be made under 2.3 other than as part of the hospitalization bill”.

However there was some relaxation and under Note No. 3(b) “Fees paid in cash will be reimbursed up to a limit of Rs. 10,000/- only, provided the surgeon/Anesthetist provides a numbered bill”.Therefore, the TPA, the op no.4 had no alternative but to pay Rs. 10,000/-.Therefore, TPA decided that matter that “Any medical expenses incurred for or arising out of - quote and all non medical expenses including convenience items for personal comfort such as telephone, television, ayah, private nursing/barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toilet items etc. guest services and similar incidental expenses - unquote and Rs. 130/- could not be paid as there was no advice of doctor as per condition no.1 as also Rs. 400/- could not be paid since there is no prescription of doctor as per condition no.1 of the policy, Rs. 3,560/- and Rs. 363/- could not be paid since they are beyond pre-hospitalisation period as per policy condition no. 2.5 which is reproduced (pre-hospitalisation medical charges upto 30 days period immediately before the insured’s admission to hospital for that illness can only be granted) and Rs. 230/- could not be paid as Bill was not in favour of anybody or in the above name of the patient and in fact there was no negligence and deficiency on the part of the Insurance Company and at the same time complainant has not prayed for relief against the op, but even then op has prayed for dismissing of this case.

But anyhow op Hospital Authority was served the notice duly and they received it as per internet postal result, but did not contest this case for which this case is heard finally.

                                             Decision with reasons

On proper consideration of the entire materials and regarding particularly the complaint of the complainant including the written version and evidence of Insurance Company op nos. 2, 3 & 4 it is clear that complainant admitted that as a Mediclaim policy holder he submitted claim and that his claim was settled and a sum of Rs. 19,149/- was paid against the claim amount of Rs. 48,813.68 paisa.From the complaint, it is found that it is admitted position that the complainant paid to the Hospital authority the total sum or Rs. 5,000/- on 27.10.2013 and Rs. 24,431/- on 02.11.2013 i.e. total Rs. 29,431/- and complainant has admitted that no direct payment, consultation to anybody was paid by the complainant.When that is the fact, then it is clear that complainant during hospitalization period for the treatment of his matter paid only Rs. 29,431/-.But Hospital Authority handed over a final Bill wherefrom it is found that grant total was Rs. 29,431/- and in that receipt it is found that there was Rs. 19,500/- which is excess which was refunded to the complainant.

But fact remains that Sanjeevani Pvt. Ltd. has produced a letter wherefrom it is found that Rs. 19,700/- was refunded to Rama Chatterjee in cash, but there is no such receipt to prove by Sanjeevani Pvt. Ltd. that Rs. 19,700/- was paid to Rama Chatterjee.Considering that letter, complainant sent a letter to op Sanjeevani Pvt. Ltd. for refund of the said Rs. 19,700/-.But Sanjeevani Pvt. Ltd. has not returned the same and truth is that Sanjeevani Pvt. Ltd. had also not appeared before this Forum to contest this case or to deny the allegation of the complainant.

It is also fact that the Sanjeevani Pvt. Ltd. op no.1 did not supply the detail bill and fact remains that in the final bill, doctors’ fees are not included.But it is mandatory provision of law after payment patient is admitted to any nursing home or hospital and the entire treatment cost was paid by nursing home.Private hospital must have to submit final bill in details including doctors’ fees and other fees.But in place of that a separate bills of doctors were handed over but that is not the provision of law because the patient is admitted to an institution which is authorized by State Government and guided by the rules and regulations of the Mediclaim Establishment Act.

So, in all respect the private nursing home or hospitals are duty bound, but in respect of treatment and all other costs borne by the hospital for that treatment.Admitted position is that complainant paid the entire bill and when in the receipt it is found that Rs. 19,700/- is excessively paid and that is returned and it is the duty of doctors that it was received from Rama Chatterjee and Rama Chatterjee was reported died and there is no receipt signed by Rama Chatterjee and in respect of the receipt of Rs. 19,700/- refunded in cash.Op no.1 was received the notice and they have their lawyer and considering the fact we are convinced to hold that no doubt op no.1 acted illegally and they did not supply details final bill and for which complainant did not get some benefit from the Insurance Company.

At the same time op no.1 has failed to prove that op no.1 has refunded Rs. 19,700/- to Rama Chatterjee or the complainant.Then it is clear that complainant is entitled to get back Rs. 19,700/- from the op no.1 along with detailed bill of the final bill along with doctors’ fees etc. and there is no such provision to supply separate bill of the doctor when she was admitted to nursing home private doctor.

Considering the code of conduct of hospital authority we are convinced to hold that they have adopted an unfair trade practice and no doubt for the act of the op no.1, complainant has suffered financial loss and at the same time complainant has been harassed by the op no.1 for which the complaint succeeds exparte against op no.1 and same is dismissed against other ops.

Hence, it is

                                                       ORDERED

That the complaint be and the same is allowed exparte against op no.1 with cost of Rs. 5,000/- and same is dismissed against op nos. 2, 3 & 4 without any cost on contest.

Op no.1 is hereby directed to refund Rs. 19,700/- at once within one month from the date of this order along with detailed final bill of the treatment mentioning doctor fee etc. in the said bill with proper seal and signature of op no.1 and it must be complied within 30 days from the date of this order failing which for non compliance of the Forum’s order, op no.1 shall have to pay penal damages of Rs. 10,000/- for adopting unfair trade practice and op no.1 shall have to pay this Forum within 30 days from the date of this order, even if it is found that op no.1 is reluctant to comply the order, in that case penal action u/s 25/27 of C.P. Act 1986 shall be started against them for which they shall be imposed further penalty and fine.