DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA (PUNJAB)
CC No. 152 of 11-04-2011 Decided on : 30-11-2011
Gurtej Singh aged 64 years S/o Sh. Sucha Singh R/o Village Dhadhey, District Bathinda. .... Complainant Versus
ICICI Lombard, Legal Office, Bawa Tower, Bandra Kurla Complex, Mumbai through its Managing Director. Sr. Branch Manager, ICICI Lombard Opposite 100' Road, Bathinda. MEDINDIA Health Care (TPA) Ltd., SCO 121-122-123 Second Floor, Sector 34-A, Chandigarh through its MD/Partner/GM President/Chairman The Dhadhy Cooperative Agricultural Society V&PO Dhadhey through its Secretary Punjab Cooperative Society, Chandigarh Punjab through its Registrar Delhi Heart Institute and Research Centre, 40 ft Road Namdev Nagar, Bathinda, through its Owner/Partner/President/M.D.
..... Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM Smt. Vikramjit Kaur Soni, President Sh. Amarjeet Paul, Member Smt. Sukhwinder Kaur, Member
For the Complainant : Sh. Ashok Gupta, counsel for the complainant For the Opposite parties : Sh. Vinod Garg, counsel for opposite party Nos. 1 to 3. Sh. Harraj Singh, counsel for the opposite party Nos. 4 & 5. Sh. Jasbir Singh, authorized representative of opposite party No. 6. O R D E R
VIKRAMJIT KAUR SONI, PRESIDENT The instant complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 as amended upto date (here-in-after referred to as 'Act'). In brief, the case of the complainant is that the opposite party Nos. 4 & 5 are running Health Welfare Scheme for farmers through out Punjab. As per scheme if consumer get policy by paying membership fee, he and his family become beneficiary of policy and in case of any mishap, the member could get cashless treatment from hospitals including Delhi Heart Institute & Research Centre, Bathinda. The scheme is known as Bhai Ghanhya Sehat Sewa Scheme. The complainant became member of scheme and cashless policy No. 401600003117, MD1D No. being MD-15-BGSS-001078470-1 issued to the complainant by opposite party No. 1 & 2 through opposite party No. 3 who is their agent. The policy was valid from 1-12-2010 to 31-1-2011. The complainant suffered heart problem and stent was put in the relevant portion of his body on 9-11-2010. He remained admitted in Delhi Heart Institute & Research Centre, 40 Ft. Road, Namdev Marg, Bathinda w.e.f. 9-11-2010 to 18-11-2010. He spent more than Rs. 2.00 Lacs on medicines and hospital charges. However, a bill for an amount of Rs. 1,70,786/- was to be paid by insurer. The complainant also spent Rs. 10,000/- for transportation charges. The complainant filed the claim with opposite party Nos. 3 & 4 who further referred it to opposite party Nos. 1 and 3. A claim for an amount of Rs. 96,000/- was sanctioned on 21-1-2010, but the opposite parties paid a sum of Rs. 86,000/- directly to the doctor. The remaining amount of Rs. 84,786/- was paid by the complainant on 18-11-2010 as the doctor was not discharging him although the entire payment was to be paid directly by the insurer to the hospital authorities. Hence, he has filed the present complaint. The opposite party Nos. 1 to 3 filed their joint written reply and denied that complainant spent Rs. 2,00,000/- on medicines and hospital charges or Rs. 10,000/- as transportation charges or an amount of Rs. 1,70,786/- was payable by them. It has been admitted that a sum of Rs. 96,000/- was sanctioned. It has been pleaded that the said amount was sanctioned as per terms and conditions of the policy and as per agreement between opposite party No. 1 to 3 and empanelled hospitals and doctor. The amount of Rs. 96,000/- was paid as under i.e. PTCA Package Charges Rs. 45,000/-, Cost of Stent Rs. 47,000/-, Room Charges for ICU charges Rs. 3200/- for two days, Room Charges of Rs. 400/- for two days and doctor charges of Rs. 400/-. Medicines, consumables, Investigation charges are all covered under package which already cover under Rs. 45,000/-. Therefore, no claim is payable. It has been pleaded that overall limit of payment of claim in one case is upto maximum of Rs. 1,50,000/-. The opposite party No. 4 filed separate written reply and pleaded that the member/beneficiary has been clearly informed that the complete financial and legal liabilities, if any, arising consequent to the operationalization of the scheme or the policy, would rest exclusively and unconditionally with the TPA and the Insurance Company i.e. opposite party Nos. 1 to 3 and the members would not hold the trust responsible in any manner whatsoever, for any matter, whatsoever arising consequent to the operationalization of the scheme. The role of the Trust is only confined to the passing on the premium paid by the members to the Insurers on their behalf. The opposite party No. 4 has nothing to do with the settlement of the claim nor it is the claim settling authority. The opposite party Nos. 1 to 3 are the settling authorities. It has been pleaded that the maximum amount for heart treatment permissible under the scheme is Rs. 1,50,000/- and the excess amount, if any, is to be borne by the beneficiary. The opposite party No. 5 filed separate written reply and pleaded that members/beneficiaries have been clearly informed that the complete financial and legal liabilities, if any, arising consequent to the operationalization of the scheme or the policy would rest exclusively and unconditionally with ICICI Lombard GIC Ltd., opposite party Nos. 1,2 & MD India Health Care (TPA) Pvt. Ltd, opposite party No. 3. The ICICI Lombard GIC Ltd., was appointed as insurer by the Trust which has appointed MD India Health Care Services as Third Party Administrator (TPA) to implement the scheme. Third party Administrator was to issue Identity cards to inspect hospitals and recommend to the Trust for their empanelment, to grant authorizations, to settle the claims, to make the payments to empanelled hospitals for providing cashless services to the beneficiaries of the scheme. It has been further pleaded that opposite party Nos. 1 to 3 are the claim settling authority under the Bhai Ghanhya Sehat Sewa Scheme. The maximum amount for Heart treatment permissible under the scheme is Rs. 1,50,000/- and excess expenditure, if any, was to be paid by the beneficiary. There is provision for cashless treatment in the empanelled hospitals and it is on reimbursement basis in Govt. Hospitals. The opposite party No. 6 filed separate written reply and pleaded that patient was admitted on 9-11-2010 in the hospital with complaint of chest pain referred to both shoulders. He did not reveal of his membership with BGSSS in his hospital at the time of hospitalization. He was firstly stabilized through medical therapy. On 12-11-2010 his Coronary Angiography was done which revealed 99% blockage of LAD vessel & 20% blockage in LA vessel leading to heart. After three days of his admission the relatives of patient informed opposite party No. 6 about his being member of BGSSS. The fax of pre-authorization for treatment was sent to MD India Mohali, TPA but till discharge of patient no sanction was received. The patient was treated for 10 days in ICCU wherein his Coronary Angioplasty (Stenting) was also done. He remained admitted from 9-11-2010 to 18-11-2010. The complainant was liable to pay the expenses of hospital bill Rs. 1,70,786/- in which Rs. 39,246/- were spent on medicine to control the heart diseases besides other relevant expenses. The opposite party No. 6 admitted that an amount of Rs. 86,000/- received through cheque from TPA was refunded to the complainant. The opposite party No. 6 denied that complainant had paid remaining amount of Rs. 84,786/- on 18-11-2010 in excess to its bill. The complainant willingly cleared the bill of Rs. 1,70,086/- without sanction of TPA. The opposite party No. 6 has further pleaded that cheque amount of Rs. 86,000/- received from TPA was refunded to complainant though the TPA did not pay the bill's amount in full to his hospital. If the bill of Rs. 1,70,786/- approved, the same would be refunded to the complainant. Parties have led their evidence in support of their respective pleadings. Arguments heard. Record alongwith written submissions submitted by the parties perused. The learned counsel for the complainant submitted that the complainant suffered heart problem and stent was put in the relevant portion of his body on 9-11-2010. He remained admitted in Delhi Heart Institute & Research Centre, 40 Ft. Road, Namdev Marg, Bathinda w.e.f. 9-11-2010 to 18-11-2010. He spent more than Rs. 2.00 Lacs on medicines and hospital charges. The complainant filed the claim with opposite party No. 3 & 4 who further referred it to opposite party Nos. 1 and 3. A claim for an amount of Rs. 96,000/- was sanctioned by the opposite parties on 21-1-2010, which was paid directly to doctor i.e. opposite party No. 6. He submitted that the remaining amount of Rs. 74,786/- was paid by the complainant on 18-11-2010 as the doctor was not discharging him although the entire payment was to be paid directly by the insurer to the hospital authorities as the treatment under the policy in question is cashless. The learned counsel for opposite party No. 1 to 3 submitted that an amount of Rs. 96,000/- was sanctioned as per terms and conditions of the policy and as per agreement between opposite party No. 1 to 3 and empanelled hospitals and doctor. The amount of Rs. 96,000/- was paid as under i.e. PTCA Package Charges Rs. 45,000/-, Cost of Stent Rs. 47,000/-, Room Charges for ICU charges Rs. 3200/- for two days, Room Charges of Rs. 400/- for two days and doctor charges of Rs. 400/-. Medicines, consumables, Investigation charges are all covered under package which already cover under Rs. 45,000/-. Therefore, no claim is payable. He further submitted that overall limit of payment of claim in one case is upto maximum of Rs. 1,50,000/-. The submission of learned counsel for opposite party Nos. 4 & 5 is that the role of the Trust is only confined to the passing on the premium paid by the members to the Insurers on their behalf. The opposite party No. 4 has nothing to do with the settlement of the claim nor it is the claim settling authority. He further submitted opposite party Nos. 1 to 3 are the claim settling authority under the Bhai Ghanhya Sehat Sewa Scheme. The maximum amount for Heart treatment permissible under the scheme is Rs. 1,50,000/- and excess expenditure, if any, was to be paid by the beneficiary. These are undisputed facts between the parties that the complainant became member of scheme and cashless policy No. 401600004117, MD1D No. being MD-15-BGSS-001078470-1 issued to the complainant by opposite party No. 1 & 2 through opposite party No. 3 who is their agent, valid from 1-12-2010 to 31-1-2011 vide Ex. R-2 and ID Card Ex. C-2 was issued to the complainant. The complainant suffered heart problem and stent was put in the relevant portion of his body on 9-11-2010. He remained admitted in Delhi Heart Institute & Research Centre, 40 Ft. Road, Namdev Marg, Bathinda i.e. opposite party No. 6 w.e.f. 9-11-2010 to 18-11-2010. The version of the complainant is that he paid Rs. 1,70,786/- for his treatment to opposite party No. 6 out of which Rs. 96,000/- has been refunded to him by opposite party No. 6. Now he has claimed medical reimbursement of bills of Rs. 74,786/-. In the present case, the complainant had heart problem and stent was put which is covered in Item No. 1003 of Schedule of Rates for the Bhai Ghanhya Sehat Sewa Scheme Ex. R-17, which reads as under :- “CARDIO – THORACIC SURGERY 1003 – Coronary Baloon Angioplasty (PTCA) excluding cost of stent (P) ..... Rs. 45,000/- - Length of Stay (LOS)- 5” A perusal of Ex. R-3 an E Mail sent by Deepak Verma, Customer Care TL, MDIndia Healthcare Service (TPA) Pvt. Ltd., to ICICI Bank is reproduced hereunder :- “In this case patient Gurtej Singh admitted in Delhi Heart Institute, Bathinda hospital for the treatment of PTCA+Stenting. Hospital sent the documents with the estimated amount of Rs. 1,42,200/- for the treatment. Estimated amount was as below ICU charges for 7 days – 11200 Medicines & consumables charges – 25000 Angeography charges – 6000 Doctor charges – 700 Investigation charges – 15000 Package – 45000 Cost of stent 50,000
But in this case total amount paid to the patient Rs. 96,000
PTCA package charges – 45000 Cost of stent – 47000 ICU charges for 2 days – 3200 Room charges for 2 days – 400 Doctor charges – 400 Medicine, consumables, investigation charges all covers under package which already covers under Rs. 45,000”
As per agreement vide Ex. R-14 between MD India Health Care Service (TPA) Pvt. Ltd., i.e. opposite party No. 3 and Delhi Heart Institute & Research Centre, Bathinda, opposite party No. 6, the definition of Package Charges has been given as under :- “Package Charge : Means a fixed fee for all the necessary, customary and incidental medical expenses such as Room, ICU, ICCU, Nursing, Medical Professional Fees, OT, Medicine, Consumables, Disposables, implants etc., for the defined medical treatment.” The relevant Clauses i.e. 2.2. and 2.6 of the said MOU reads as under : “ 2.2 The PROVIDER will offer treatment under cashless service and will bill MDINDIA as per annexed rate list subject to the terms and conditions of the MOU. 2.6 It is agreed between the parties that the package will include the charges for the below :- Bed charges (General Ward), Nursing and boarding charges, Surgeons, Medical Practitioner, Consultant's fees, anaesthesia, blood, oxygen, OT charges, cost of surgical appliances, medicines & drugs, cost of prosthetic devices, implants, X-ray and diagnostic tests, food for patients and all the expenses necessarily incurred for the treatment of the specified ailment.” The final pre-discharge bill Ex R-5 of opposite party No. 6 submitted for reimbursement with MDINDIA Healthcare Services (TPA) Pvt. Ltd., is reproduced hereunder :- :(Bill Date 09-11-2010 to 17-11-2010) 1. ICCU Charges 1600X7 Rs. 11,200/- 2. Room Charges 225X2 Rs. 450/- 3. Doctor Charges 100X9 Rs. 900/- 4. Medicines Rs. 20,000/- 5. Monitoring Charges Rs. 4,000/- 6. PTCA Procedure Charges Rs. 45,000/- 7. Stent Rs. 49,350/- 8. Difib with Pacing Pads Rs. 4,000/- 9. ECHO 500X1 Rs. 500/- 10. Blood Tests+ECG Charges Rs. 10,000/- -------------------- Rs. 145400/- -------------------- As mentioned above, as per definition of package given in the agreement, the opposite party No. 6 was entitled to charge a fixed fee for all the necessary, customary and incidental medical expenses such as Room, ICU, ICCU, Nursing, Medical Professional Fees, OT, Medicine, Consumables, Disposables, implants etc., for the defined medical treatment whereas as per aforesaid bill the opposite party No. 6 charged Rs. 45000/- as PTCA Procedure Charges and Rs. 49,350/- being the charges for Stent. In addition to this, he has also mentioned in the bill for ICCU charges Rs. 11,200/-, Room charges Rs. 450/-, doctor charges Rs. 900/-, medicines Rs. 20,000/-, monitoring charges Rs. 4,000/-, ECHO Rs. 500/- and Blood tests and ECG charges Rs. 10,000/-. The PTCA Procedure charges is actually the 'package' under which head the opposite party No. 6 has charged Rs. 45,000/-. As per clauses 2.2. and 2.6 of the MOU, it was required from the opposite party No. 6 to offer treatment under cashless service and then bill MDINDIA as per annexed rate list subject to the terms and conditions of the MOU. According to rate list attached with MOU, as mentioned above, for “CARDIO – THORACIC SURGERY” the opposite party No. 6 was required to provide cashless treatment to the complainant and thereafter submit the bill with MDINDIA Healthcare Services Pvt. Ltd., as per schedule Ex. R-17 i.e. “1003 – Coronary Baloon Angioplasty (PTCA) excluding cost of stent (P) ..... Rs. 45,000/- - Length of Stay (LOS)- 5”, but the opposite party No. 6 prepared bill without relying upon the rates agreed upon between the parties. Not only this, the opposite party No. 6 charged exorbitant amount of Rs. 1,70,086/- from the complainant as it has admitted in para No. 5 at page 3 of its written reply that “ Instead patient willingly cleared out bill of Rs. 1,70,786/- in view of no sanction given by TPA.” Keeping in view the facts, circumstances and the evidence placed on file by the parties, this Forum is of the view that there is deficiency in service on the part of the opposite party No. 6 in charging such an exorbitant amount from the complainant whereas he was entitled for cashless treatment as per policy. There is deficiency in service on the part of opposite party Nos. 1 to 3 also as being the Insurer they are duty bound to get provided the cashless treatment to the beneficiaries of the policy and give instructions to the empanneled hospitals to abide by the terms and conditions of the MOU and incase non-compliance take appropriate action, whereas in the present case, the opposite party No. 6 did not provide cashless treatment and charged such an exorbitant amount from the complainant. In view of what has been discussed above, this complaint is accepted with Rs. 10,000/- as cost and compensation against opposite party Nos. 1 to 3 and 6 and dismissed qua opposite party Nos. 4 & 5. The opposite party No. 6 is directed to refund the amount of Rs. 74,786/- with interest @.9% from the date of payment till realisation to the complainant. The opposite party Nos. 1 to 3 are directed to pay Rs. 2,000/- being cost and compensation to the complainant and the remaining amount of Rs. 8,000/- of cost and compensation will be paid by opposite party No. 6 to the complainant. The compliance of this order be made within 45 days from the date of receipt of copy of this order. A copy of this order be sent to the parties concerned free of cost and the file be consigned to record.
Pronounced : 30-11-2011 (Vikramjit Kaur Soni) President ( Amarjeet Paul) Member
(Sukhwinder Kaur) Member
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