Order-15.
Date-17/06/2015.
Complainant Alok Mukherjee by filing this complaint has submitted that he is an ex-employee of the State Government of West Bengal and now he aged about 75 years and his wife Smt. Sudipta Mukherjee is also a senior citizen and they are covered under West Bengal Health Scheme – 2008 as well as Midiclaim Insurance of National Insurance Company Ltd.
Fact remains that complainant’s wife Smt. Sudipta Mukherjee was admitted on 31.07.2013 to B.P. Podder Hospital & Research Ltd. with Sepsis and various other ailments and on 07.08.2013 she was released after some treatment and recovery. The treatment of Sudipta Mukherjee are covered by both the benefits of Mediclaim Insurance and WBHS-2008 and soon after her admission into the op Hospital following the terms and conditions of WBHS-2008 as well as Mediclaim Insurance Policy both pro forma op No. 2 through Pro forma op no.3 and also Pro forma op no.4 were intimated accordingly and on the date of discharge, op Hospital raised the total Bill of Rs. 94,042.96 paisa and sent the same to op no.3 for indemnification of payment of cost incurred. Pro forma op no.3 after necessary verifications issued the authorization letter on 07.08.29013 for the treatment of Sudipta Mukherjee on Cashless Basis and guaranteed payment of Rs. 88,000/- from pro forma op no.3 against the said Bill compelled the complainant to pay Rs. 20,621/- only instead of Rs. 6,042.96 paisa at the time of release of complainant’s wife and in addition to the amount mentioned in para-5 complainant also paid Rs. 1,800/- towards charges for deployment of Special Attendants under the advice of treating doctor for better management of the patient.
Keeping in view of the Provision under Clause 9(vii) of Memo No. 3474-F dated 11.05.2009 Read with Memo No. 6508-F(MED) dated 27.07.2012 of Finance Audit Department, Goveernment of West Bengal, complainant availed of the Cashless Scheme of Mediclaim Insurance of Pro forma op nos. 2 & 3 as well as the benefits of WBHS-2008. So, in consideration of the health condition of the wife of the complainant and the treating doctor advised round the clock deployment of Spl. Attendants for better management of the health care of her and complainant acted in accordance to doctor’s advice and paid the charges for the same from his own pocket because the same was not payable by the Pro forma op nos. 2 & 3. But as per Clause 9(v) of Memo No. 3474-F dated 11.05.2009 of Finance Audit Department, Government of West Bengal, complainant is entitled to get full reimbursement of charges paid for deployment of Spl. Attendant.
That after release of the spouse of complainant following the Provision under C1.9(vii) of Finance Deptt., Government of West Bengal Memo No. 3474-F approached op Hospital for authentication and certification of duly filled-in forms for claiming reimbursement of charges which were not paid by the insurer along with the charges for engagement of Spl. Attendant while she was treated as in-patient of op Hospital. But op Hospital without any cogent reason, did not agree to authenticate and certify those forms and as such due to purported deficient service of the op Hospital. Besides foregoing on meticulous scrutiny of the Bills raised by the op Hospital, complainant observed that op Hospital realized the charges for Bed Pan, preservation of Medical Records and apart from that also charged for non-medical consumables the quantum for which assertively appeared to be exaggerated one.
Thereafter complainant sent a letter to the op Hospital for authenticating the requisite and documents following the reimbursement of mediclaim expenses under WBHS-2008 so that complainant could submit the documents and requisites for due authentication and certification. But op Hospital ignored the said even after reminder dated 15.02.2014. Thereafter the matter was reported to op no.4 for giving specific directions to the Hospital empaneled under WBHS-2008 and same was not heard by the op no.4. In the meantime complainant took the matter of disputes with Pro forma op no.3 by e-mail on 27.08.2013 with request for appraisal about the reason for charging Rs. 20,621.06 paisa instead of Rs. 6,042.96 paisa and op no.3 replied that the matter shall be taken from its end with the op Hospital for breakup and subsequently op no.3 informed the complainant that op Hospital realized the Room Rent charges of Rs. 9,906/- and complainant is entitled to get back the same.
That apart from foregoing op Hospital illegally realized Rs. 500/- for preservation of the Medical Records and also Billed for various non-medical items like Bed Pan and that op Hospital is a PPN Hospital of Pro forma op no.2 as well the said Hospital is empaneled Hospital under WBHS-2008 and op Hospital is liable as per terms and conditions of the National Insurance Policy. No doubt op Hospital submitted that it drew bill for Rs. 9,906/- in excess towards Room Rent, but it will appear from the document that Op Hospital realized Rs. 32,800/- in respect of Rs. Charges instead of Rs. 4,920/- only and in the act as noted on the part of the op Hospital is completely unfair trade practice and also denial for authentication for claim reimbursement by the op Hospital is also negligent and deficient manner of service and in the above circumstances, complainant is entitled to get refund the admitted amount excess paid as charge of Rs. 9,906/- and also refund of Rs. 500/- which was illegally realized and also 50 percent of the total Bill because it was realized as unauthenticated amount and further relief for negligent and deficient manner of service and also for redressal.
On the other hand op no.1 by filing written statement submitted that the entire complaint is false and fabricated, imaginary, concocted, baseless and further submitted that there was no ground for realization of any extra amount and the Bill was prepared and handed over to the complainant after necessary correction and Rs. 1,800/- was paid as Special Attendants charges as per advice of the treating doctor which was admitted by the complainant.
Further it is submitted that benefits under WBHS is not applicable to the complainant /patient once she opted and availed of the medical benefits under the Mediclaim Insurance from op nos. 1 , 2 & 3. Therefore question of preparing bill and/or authentication or certification on the prescribed forms under the said Govt. of W.B. Scheme did not arise and when the complainant availed of and enjoyed medical treatment and services in terms of his Medical Insurance Coverage, he is practically and legally debarred from making any claim of reimbursement of expenses for the same treatment. So there was no deficiency and negligence on the part of the op.
Practically wife of the complainant Smt. Sudipta Mukherjee was admitted on 31.07.2013 and was treated and was discharged on 07.08.2013 from op no.1’s Hospital after final recovery of treatment. No doubt op raised a Bill of Rs. 94,042.96 paisa. But Bill was forwarded to TPA Pro forma op no.3 and after verification the proforma op nos. 2 & 3 approved the bill to the extent of Rs. 88,000/- because TPA always paid the entitled bed charges as per the policy of the patient, but did not pay service charges, charges for non admissible items, patient attendant charges. But complainant opted bed category which was higher than he is entitled bed category under Mediclaim Policy. So, extra bed charge over entitled bed charge, charge of non admissible item, private attendant charge and service charge are always collected from patient/patient party before discharge. And at the time of discharge balance amount of Rs. 20,621/- was taken from the complainant at the time of discharge instead of Rs. 6,042.96 paisa, because it is true that Rs. 500/- was collected from the complainant on account of expenditure for maintenance and preservation of patient’s medical records and it is as per hospital rules and regulations.
Fact remains that as per rules all the medical papers were sent to TPA on the basis of Cashless benefit as per Mediclaim Policy and op no.1 also supplied the complainant and the allegation of excess paid charge it is to be mentioned that he availed of such fate. So, admitted charge was as per norms of the hospital for which this op no.1 has no liability and practically it is clear the allegation is false and fabricated.
On the other hand op no.2 the Insurance Company by filing written version has submitted that there was no negligence and deficiency on the part of the op no.2, op no.2 forthwith paid Rs. 88,000/- out of total Bill of Rs. 94,042.96 paisa and balance of Rs. 6,042.96 paisa are not payable under the terms and conditions of the policy and complainant also admitted that both op nos. 2 & 3 helped him to get the detail bifurcation of hospital bill. Moreover this complaint is filed against op no.1 BP Podder Hospital and against op no.2 there is no allegation, so the complaint should be dismissed against op no.2.
Decision with reasons
On proper consideration of the complaint and written version and also considering the material arguments as advanced by the Ld. Lawyers of both parties, it is found that as per WBHS-2008 and as per Finance Department (Audit Branch) Medical Cell Order No. 6508-F(MED) dated 27.07.2012 State Government of West Bengal Pensioners/family pensioners who were under the WBHS-2008 has taken a Medical Insurance Policy would be allowed to claim reimbursement of medical expenses both from the Insurance Company as well as the WBHS-2008 subject to the observance of the following procedure –
Medical reimbursement claim against the original voucher(s)/cash-memo(s) would be submitted by the pensioner/family pensioner first to the Insurance Company who would issue a certificate to the pension sanctioning authority/competent sanctioning authority regarding the amount reimbursed to the pensioner/family pensioner. The pensioner/family pensioner would then prefer the medical claim along with authenticated photocopies of vouchers/cash-memos to the concerned sanctioning authority. The sanctioning authority would then reimburse to the pensioner/family pensioner only the balance admissible amount on the basis of approved rates i.e. admissible amount minus the amount reimbursed by the Insurance Company.
Considering that order, it is clear that complainant can claim balance amount which has not been paid by the Insurance Company to his sanctioning authority or pension sanctioning authority for reimbursement and for that purpose complainant must have to follow the spirit of the order of Finance & Audit Department, Medical Cell, Government of West Bengal vide Memo No. 6508-F(MED) dated 27.07.2012 and in fact in the present case complainant has no grievance against the op nos. 2, 3 & 4. But only grievance is that op no.1 the B.P. Podder Hospital Authority who charged extra Bill. But in this case it is to be mentioned that Hospital Authority cannot charge any excess Bill as per WBHS-2008 when this Hospital is the listed PPN Hospital of the State Government of West Bengal.
So, if there is any allegation of excessive charge made by the op Hospital, in that case complainant must have to lodge a complaint to the sanctioning authority in this regard to the Government of West Bengal, Finance Audit Department, Medical Cell who investigate the matter and directs the op Hospital to rectify the bill as per contract with the op Hospital and the Government of West Bengal.
Most interesting factor is that complainant lodged a complaint to the op authority i.e. to the Finance Department. But Finance Department did not take any step which is completely unwarranted and in fact Finance Department tried to avoid their liability as per WBHS-2008 when rates of reimbursement of medical expenses for various treatments/tests/procedures have been specified under the Finance Department notification no. 3473-F dated 11.05.2009 and by that order it is specifically mentioned for medical attendance and treatment of a beneficiary shall be released on the basis of approved rates or actual rates of the concerned hospital, whichever is less, for indoor treatment and private hospitals/diagnostic centres shall charge medical expenses on the basis of package rate and the package rate is particularly clarified in the said notification, i.e. accrued rates as specified in Rules 5 of the West Bengal Services (Medical Attendance) Rules, 1964 of WBHS-2008 and in the said order it is specifically mentioned that what type of facility from hospital shall have to get and in fact op has not filed any application to the concerned authority as mentioned in Clause-12 regarding claim of medical expenses and claim for reimbursement of balance medical expenditure which has not been paid by the Insurance Company to the concerned authority within the specified period of three months of the completion of treatment. But he has brought the allegation against the Hospital authority about the excess charge and as per said notification, it is found that complainant ought to have filed such claim before the Pension Sanctioning Authority or the competent authority or head office for reimbursement of the balance amount not paid by the Insurance Company after collecting such certificates from the Insurance Company in respect of which Insurance Company has not paid and in respect of the balance admissible amount complainant ought to have filed such application before the op no.4, but that has not been done.
Now we have gathered that Bill was supplied to the complainant by the op no.1 and no doubt complainant paid the entire amount out of that Rs. 88,000/- was paid by the Insurance Company and balance has not been paid. But Insurance company subsequently reported to the complainant that complainant is also entitled to Rs. 9,906/- out of Rs. 20,621/- for reimbursement. But complainant did not file any such claim for reimbursement to the Insurance Company and already op Hospital reported to the complainant that Rs. 9,906/- Room Rent charge, Rs. 7,038/- for service charge, Rs. 3,177/- for evening and morning attendance and Rs. 500/- for maintenance and preservation of medical records were released to the complainant in respect of that a Bill of Rs. 20,621/- has been issued.
Considering all the above fact and circumstances, we find that complainant has actually brought allegation against the op no.1 for charging extra charges in respect of his treatment etc. When this matter can only be adjudicated by the Finance Department when as per PPN this Hospital B.P. Podder & Research Centre must have to follow the rules of WBHS-2008 when he is a partner of the said PPN and this matter can only be dealt with by the Finance Department in this regard. But Finance Department has not taken any step which is completely illegal and uncalled for but we have failed to understand why even after submission of complaint by the complainant to the Finance Department, Finance Department is found silent in this regard and in this context it is to be mentioned that. It is proved that this op Hospital signed the agreement on the basis of MoU with the authority of WBHS-2008 under the Finance Department, Government of West Bengal and op no.1 is recognized hospital as per said MoU agreement. So, if there is any dispute in between the member of WBHS and the Hospital Authority under whom the said member got treatment, in that case the matter shall be decided by the WBHS Authority or the Finance Department, if any complaint is lodged by the said employee or ex-employee along with prayer for reimbursement of balance amount of the treatment after payment made by the Insurance Company.
Another factor is that the WBHS-2008 Authority has already passed such necessary order and details about getting the facilities by the employee or ex-employee and settlement of claim shall be made in respect of Government employee or retired employee shall be made under the WBHS-2008. So, we find that the matter should be decided by the WBHS Authority of the Finance Department, Government of West Bengal. So, we are passing such necessary order in this regard by disposing of the complaint accordingly.
Hence, it is
ORDERED
That the complaint be and the same is allowed with cost of Rs. 3,000/- against op no.1 and same is dismissed against op no.2 on contest without any cost and against other ops as complainant has not prayed for relief and same is also dismissed against op no.3 without any cost but allowed exparte against op no. 4.
Complainant is directed to file the claim in respect of non-disbursed amount by the Insurance Company before the Insurance Company in respect of Rs. 9,906/- in respect of which Insurance Company has already desired to disburse that amount and after payment of that amount, complainant shall have to take a certificate from the Insurance Company as per Finance Audit Department, Medical Cell Memo No. 6508-F(MED) dated 27.07.2012 and thereafter shall file such application for reimbursement of the balance amount to the concerned or competent sanctioning authority for disbursement and also shall have to file such complaint as brought against the op no.1 Hospital before that Authority within two months from the date of this order.
On receipt of such application by the Pension Sanctioning Authority or Computation Sanctioning Authority as per WBHS-2008, the said authority including Special Secretary, Finance Department (Audit Branch), Government of West Bengal to decide the complaint of the complainant whether op no.1 has charged excess bill than that of the fixed charges as fixed by the MoU in between the Finance Department, Medical Cell, Government of West Bengal and the op no.1 and if it would be found that op no.1 has charged excess amount than that of the fixed amount as per PPN in that case Finance Secretary is directed to take such penal step against op no.1 and if it is found that excess amount has been charged by the op no.1 in that case that amount shall be released by the op no. 1 being directed by the State Government and thereafter in appropriation of payment by the Insurance Company the WBHS Authority shall decide balance amount what complainant is entitled to get reimbursement. But only balance amount shall be reimbursed by the Finance Department, Government of West Bengal.
Complainant is directed to comply this order within two months and Special Secretary, Finance Department, Medical Cell, Government of West Bengal is hereby directed to dispose of the matter as per spirit of the order and to report this Forum the final result in this regard after proper decision on the basis of the complaint of the present complainant.
At the same time B.P. Podder & Research Centre is hereby directed to comply the order if any passed by the Finance Department (Audit) Medical Cell accordingly failing which penal action shall be started against the op no.1.
