Punjab

Ludhiana

CC/21/547

Manpreet Kaur - Complainant(s)

Versus

IVY hospital - Opp.Party(s)

Shamsher Singh

10 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No: 547 dated 10.12.2021.                              Date of decision: 10.09.2024. 

 

Manpreet Kaur wife of Shri Amanpreet Singh, resident of House No.823/16, House Near Ground of A.S. Modern School, Malerkotla Road, Khanna, District Ludhiana.

                                                                                      ..…Complainant

                                                Versus

1. IVY Hospital, G.T. Road, Khanna-141401, through its Director/M.D./Incharge.
2. State Health Agency Punjab, BSNL Circle Office, Sector 34A, Sector 34, Chandigarh-160022, through its Secretary/Chief Executive Officer.
3. The New India Assurance Company Ltd., SCO No.2939-2940, First Floor, Sector 22-C, Chandigarh-160022.                                                                                                                     …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Shamsher Singh Lohat, Advocate.

For OP1                         :         Sh. Deepak Makhija, Advocate.

For OP2                         :         Sh. Gagandeep Saini, Advocate.

For OP3                         :         Sh. R.K. Chand, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant is a holder/beneficiary of Ayushman Bharat-Sarbat Sehat Bima Yojna vide card No.PF1CFN1C4. As the complainant was pregnant so she approached OP hospital for her delivery after making enquiry of OP hospital being empanelled hospital with Ayushman Bharat-Sarbat Sehat Bima Yojna and a board of having registered with said scheme was displayed by OP hospital. The complainant stated that she also got confirmed from the reception of OP hospital who assured to provide cashless facility of treatment for her delivery and treatment of her newly born child after delivery, if any ailment is found. Relying upon assurance of the OPs, the complainant got admitted in OP hospital on 16.08.2021 vide Reg. Id 970014, UHID 216239 where she gave birth to twin daughters. The complainant remained admitted in OP hospital from 16.08.2021 to 26.08.2021 and the OP hospital started demanding a bill amount of Rs.2,04,790/-. The complainant further stated that she requested that she is registered under Ayushman Bharat-Sarbat Sehat Bima Yojna and was assured by the OP hospital to provide cashless treatment facility but they refused to provide the benefit of cashless facility and even refused to discharge her without depositing of the amount. As such, the complainant had to deposit the amount under compelling circumstances which amounts to deficiency in service and unfair trade practice on the part of OP1 due to which the complainant has suffered physical and mental pain, agony, harassment etc. which entitled her for compensation. Even the complainant sent legal notice dated 28.10.2021 upon the OPs through Sh. Shamsher Singh Lohat, Advocate. The OPs sent an evasive reply by taking plea that the complainant had not disclosed the factum of insurance under Ayushman Bharat-Sarbat Sehat Bima Yojna to them. Hence this complaint whereby the complainant has prayed for issuing directions to the OPs to reimburse the claim amount of Rs.2,04,790/- along with compensation of Rs.2,00,000/- and litigation expenses of Rs.21,000/-.

2.                Upon notice, OP1 appeared and filed written statement and assailed the complaint by taking preliminary objections as well as preliminary submissions on the ground of maintainability; the complainant being an abuse of process of law; lack of cause of action; concealment of facts; the complainant being estopped by her act and conduct; the complaint being non-joinder of necessary parties; the complaint being misconceived etc. OP1 stated that the complainant was firstly admitted on 08.08.2021 wherein LSCS (Lower Segment Cesarean Section) was done and she was blessed with twin daughters on 10.08.2021. Thereafter, her new born babies were sick due to which the complainant and her babies remained in the hospital and were finally discharged on 13.08.2021 but the complainant concealed this fact. OP1 further stated that before admission of the complainant and her new born babies, each time in the hospital, the complainant and her attendants were duly counseled and their requisite written consents were taken. On 08.08.2021, husband of the complainant Mr. Amanpreet Singh gave written consent for admission and treatment of the complainant and new born babies affirming that he do not have any health card of health insurance or medical insurance and they are not beneficiary under any Governmental Health Scheme or any medical insurance and as such, they had to pay treatment charges to OP1 in cash against for which OP1 issued receipts. Further on 16.08.2021, new born babies were again admitted in OP1 hospital and discharged on 26.08.2021. Before admission of new born babies, father-in-law of the complainant namely Mr. Karamjit Singh gave written consent affirming that they do not have any health card of health insurance or medical insurance and they are not a beneficiary under any Governmental Health Scheme or any medical insurance. OP1 further stated that on 03.09.2021, one of the new born baby was again admitted in their hospital and the complainant took LAMA on 04.09.2021. Even before admission of the baby, the complainant and her attendants were duly counseled and required consents were taken from Mr. Amanpreet Singh. In the afternoon of 04.09.20-21, it is for the first time when husband of the complainant showed Ayushman Bharat Card to OP1 hospital and staff of OP hospital checked and verified the card but the complainant took LAMA before proceeding further. Hence, the complainant and her attendants did not show Ayushman Card at the time of first and second admission nor claimed any benefit under said card.

                   OP1 further stated that there is a procedure to take approval or to receive the claim amount from the insurer of the patient. Further when the patient comes to their hospital, the patient/attendant are requested to show insurance document/policy/health card etc., if any. Thereafter, document/policy/health card etc. are verified online from the web portal of the concerned authority and on receiving the approval of claim/claim amount from the concerned authority, the patient/attendant are informed accordingly on the same day/at the time of admission in the hospital. In this manner patient/beneficiaries are given the benefits of insurance оr any health card issued by any government/private authority. According to OP1, if the patient/attendant fails to show beneficiary/health card/insurance policy etc. to the hospital at the time of admission of the patient, then answering hospital is unable to treat the patient under cash less scheme because answering hospital cannot claim/receive the cashless treatment amount from the concerned authority afterwards. It is further clarified here that in case, the patient show the health card/insurance policy etc. after the admission of patient in the hospital then only 5 days back treatment charges from the date of showing health card can be claimed from the concerned authority as per the guidelines and policies of the Ayushman Bharat Card. In the present case, the patient/attendant had shown the health card on 04.09.2021 to them for the very first time, for the reasons best known to them and OP1 asked to consider the case of complainant under cashless scheme only for this admission but complainant/attendant refused the same and took LAMA (Left Against Medical Advice) on 04.09.2021.

                   On merits, OP1 reiterated the crux of averments made in the preliminary objections and preliminary submissions. OP1 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                OP2 filed separate written statement and assailed the complaint by making submissions identical and similar to that of OP1.

4.                OP1 filed an application for impleading New India Assurance Company Limited as party which was allowed vide order dated 10.08.2022.

5.                Upon notice to newly impleaded party, OP3 appeared and filed separate written statement and assailed the complaint by taking preliminary objections on the grounds of maintainability; lack of jurisdiction; the complainant is not their consumer; the complainant is estopped by her own act and conduct; the complainant has not come with clean hands, concealment of material facts etc. OP3 stated that the complainant had not availed any services from it and even she has not pleaded any negligence on its part. Further there is no privity of contract between the complainant and OP3.

                   On merits, OP3 reiterated the crux of averments made in the preliminary objections. OP3 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

6.                In evidence, the complainant tendered her affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 to Ex. C13 and closed the evidence.  

7.                On the other hand, the counsel for OP1 tendered affidavit  Ex. DA of Sh. Ravinder Minhas, Chief Liaisoning Officer of OP1 hospital along with documents Ex. OP1/ to Ex. OP1/7 and closed the evidence.                             

                   The counsel for OP2 tendered affidavit Ex. R2/A  of Ms. Gurpreet Kaur, Authorized Person of OP2 along with documents Ex. R1 to Ex. R3 and closed the evidence.          

                   The counsel for OP3 tendered copy of insurance policy Ex. OP3/1 and closed the evidence.      

8.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statements along with affidavits and documents produced on record by the parties.

9.                Undisputably, the complainant, a card holder (Ex. C1) and beneficiary of Ayushman Bharat-Sarbat Sehat Bima Yojna was firstly admitted with OP1 hospital on 08.08.2021 where LSCS (Lower Segment Cesarean Section) was performed and the complainant was blessed with twin daughters on the same day. The complainant was discharged on 10.08.2021 vide discharge summary dated 10.08.2021 Ex. OP1/2 (page 21). On the same day, due to sickness of new born babies, the complainant along with babies remained under treatment from 12.08.2021 and was discharged on 13.08.2021 vide discharge summary Ex. OP1/2 (page 23). However, on 16.08.2021, again new born babies were brought to OP1 hospital for treatment where they remained hospitalized till 26.08.2021. On 03.09.2021, as well, one of the new born baby came for treatment but the complainant along with baby left the hospital against medical advice (LAMA) on 04.09.2021. At the time of hospitalization for aforesaid periods of hospitalization from 08.08.2021 to 26.08.2021 except 04.09.2021, OP1 hospital has categorically asserted that neither the complainant nor her attendants or any other relative disclosed her to be beneficiary of said Ayushman Bharat Scheme. Rather on 08.08.2021, 16.08.2021, 03.09.2021, they furnished declaration Ex. OP1/3, Ex. OP1/4 and Ex. OP1/5 that they are not the beneficiary of any health insurance scheme and undertook to pay expenses of the hospital by themselves. The aforesaid documents belies the stand of the complainant that despite showing the card of Ayushman Bharat Yojna, OP1 had denied the cashless facilities to the complainant. Rather there is a concealment of material facts on the part of the complainant which disentitles them from the equitable relief claimed by her against OP1 and OP3. In this regard, reference can be made to 2022(3) Apex Court Judgments 511 (SC) in case titled Yashoda (Alias Sodhan) Vs Sukhwinder singh & Ors. wherein the Hon’ble Supreme Court of India has made the following observations:-

“Clean hands – Non disclosure of filing of earlier suit and withdrawal thereof without liberty to file another suit – It is a material fact – Plaintiff thus failed to approach Court with clean hands – Judgment and decree passed by trial Court dismissing suit upheld.”

Further reference can be made to 2022(1) Civil Court Cases 209 (SC) in K. Jayaram & Ors. Vs Bangalore Development Authority & Ors. whereby the Hon’ble Supreme Court has made the following observations:-

“Suppression of material fact – Non disclosure of filing of suit and its dismissal and also dismissal of appeal – Appellants have to be non suited on the ground of suppression of material fact – They have not come to Court with clean hands and they have also abused the process of law – They are not entitled for the extraordinary, equitable and discretionary relief.”

As such, applying ratio of aforesaid citations, the complaint deserves dismissal  as against OP1 and OP3.

10.              The Consumer protection Act, 23019 has been enacted to protect the interest of consumers and it is a statute made for public and Commissions are by virtue of its ‘Preamble’ are called upon to liberally construe the provisions of this Act in to impart substantial justice to the Consumers. So, therefore, it would be just and appropriate, if OP2, who is stated to be a Nodal agency of Ayushman Bharat-Sarbat Sehat Bima Yojna, be directed to consider and settle or to get it settled from the concerned insurance company within 30 days in case the complainant prefers its reimbursement claim along with requisite documents. However, the complaint as against OP1 and OP3 deserves dismissal.

11.              As a result of above discussion, the complaint is partly allowed with an order that the complainant is directed to submit her claim regarding  hospitalization with OP1 Hospital from 08.08.2021 to 10.08.2021, from 12.08.2021 to 13.08.2021, from 16.08.2021 to 26.08.2021 and from 03.09.2021 to 04.09.2021 along with requisite documents with OP2 within 30 days from the date of receipt of copy of order and further OP2 will consider and settle or get it settled from the concerned insurance company within 30 days from the date of submission of claim by the complainant. However, there shall be no order as to costs. The complaint as against OP1 and OP3 is hereby dismissed. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.       

12.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:10.09.2024.

Gobind Ram.