Judgment : Dt.30.10.2017

Shri S. K. Verma, President.

            This is a complaint made by one Sri Prithiviraj Sen Eshore, S/O Sri Pravat Sen Eshsore, resident of Flat No.231, Block No.36, Parnasree Central Govt. Quarters, P.O. & P.S. Parnasree, Kolkata-700 060 against M/s B.P.Poddar Hospital & Medical Research Ltd. a body corporate having Hospital at 71/1, Humayun Kabir Sarani, New Alipore, Block-G, Kolkata-700 053, praying for a direction upon the O.P. to refund Rs.42,000/- which was illegally charged in excess of package rate and which was paid by the Complainant and compensation of Rs.50,000/- for harassment and another compensation of Rs.50,000/- for mental agony and cheating and litigation cost of Rs.5,000/-.

            Facts in brief are that Complainant on enquiry was given to understand from OP that there was package treatment of maternity cases at rate ranging from Rs.26,500/- to Rs.46,500/- inclusive of charges of O.T., Room rent, anaesthetist, OP Assist. and cost of medicine used in OP and exclusive of surgeon’s fee, cot of investigation and medicine used after delivery. The maximum package limit of Rs.46,500/- is said to be applicable in case of C-section delivery with allotment of a single occupancy room for five days while minimum limit of Rs.26,500/- is applicable in case of normal delivery with allotment of general bed for 3 days’ stay in hospital. Complainant got his wife admitted into OP’s hospital on 1.2.2016 at 12.50 p.m. as an expectant mother under care of Dr. J. K. Basu. Complainant’s wife gave birth to a baby on the same day and was discharged on 5.2.2016. At the time of making the payment of the bill, the Complainant was astonished to find that the bill was not prepared in accordance with hospital package rate which was communicated to him before admission of his wife into hospital. Complainant took up the matter with patient service desk where he was informed for the first time that cashless facility is given by the Insurance Company and the package treatment facility of the hospital cannot be availed at the same time. Complainant was advised to select one facility only and give the option in writing to the DMS of the hospital. Accordingly, Complainant made his option by a letter to the DMS of the hospital requesting him for cancellation of cashless facility under medical insurance scheme and demanding revision of bill in accordance with package rate i.e. request was allowed by the DMS and he was asked to wait for an hour within which preparation of revised bill as per package rate was to be completed. Complainant was also given Xerox copy of letter on which sanction was accorded by the DMS under his signature. Complainant enquired about progress of the revised bill after an hour that the package facility could not be allowed and Complainant would have to pay the bill as already prepared. As the persons in insurance company desk and patient service desk could not give satisfactory reply stating reasons for change of decision. Complainant became dissatisfied. Complainant paid the entire amount of Rs.1,07,887/-. The moment Complainant asked for written reply and hospital started playing game using Complainant as a shuttle cork. Complainant was made to move from patient service desk to business development desk. In the evening, at 6.45p.m., it was found to have been signed by the same DMS. There was no mention about earlier sanction and subsequent cancellation of the same. The reason for rejection of Complainant’s claim was not at all applicable in case of the Complainant since he had not availed the cashless facility under medical insurance scheme and the entire amount of the bill was paid by him.

            Complainant submitted that if the OP does not have any package tie up with TPA and if OP considers the same has close connection with eligibility of availing package treatment, why it was not disclosed to the petitioner before admission. Further, the question of OP of not having package tie with TPA does not arise in case of the petitioner since cashless facility was given up and entire bill amount was paid by the Complainant. Complainant further has submitted that OP by giving an understanding about package rate prior to admission subsequently at the time of discharge, in fact cheated the Complainant. So, Complainant filed this case.

            OP filed written version and denied the allegations of the complaint. OP has stated that Complainant is not a consumer and he did not hire the service of the OP. Further it has stated that it is not true that OP on his end did not provide the service as expected by the Complainant. Complainant did not make TPA a party to this case. So, this case is bad for non-joinder of necessary party. Further, OP has stated that the Complainant’s wife was admitted to the hospital on 1.2.2016 as an expectant mother. After being admitted at bed No.320 she gave birth to a baby on the same day and thereafter was discharged on 5.2.2016. Complainant and his wife were explained about various packages available and the charges that were inclusive in treatment packages at the time of admission. Complainant submitted his wife’s documents in order to avail medical insurance facility from Medi Assist India TPA Pvt. Ltd. and necessary documents were duly sent to the said Medi Assist India TPA Pvt. Ltd. and initial approval to the tune of Rs.35,000/- was made for the Complainant’s wife. Complainant was handed over the final bill to the tune of Rs.1,07,887/- which was also sent to Medi Assist India TPA Pvt. Ltd. for final approval of the total bill. At that time Complainant raised objection stating that Complainant had opted for treatment package facility on which Hospital informed Complainant that as per protocol no patient can avail treatment facility and cashless facility from medical insurance company at the same time. Any patient opts for treatment package facility has to pay the bill by himself or herself. Similarly, any patient opted for cashless facility cannot be provided package facility. Complainant wrote a letter to the concerned authority of hospital for cancellation of cashless facility with further request to opt for hospital package system. Documents had already been sent to Medi Assist India Pvt. Ltd. for final approval of the said bill. He could not avail treatment package facility and is to pay the entire bill amount himself. Complainant has not alleged medical negligence. Complainant was not clear on his own as to whether he intends to avail cashless facility or package facility. So, OP has prayed for dismissal of this complaint.

Decision with reasons

            Complainant has filed affidavit-in-chief to which OP has filed questionnaire to which Complainant filed affidavit-in-reply. Similarly, OP has filed affidavit-in-chief to which Complainant filed questionnaire to which OP filed affidavit-in-reply.

            Main point for determination is whether Complainant is entitled to the reliefs as prayed for.

            On perusal of the complaint petition, it appears that Complainant has prayed for refund of Rs.42,000/-. In this regard, on perusal of the affidavit-in-chief, questionnaire and affidavit-in-reply of the respective parties, it appears that contention of the Complainant is that he was deprived from the package facility of the OP which was within the range of Rs.26,500/- and to Rs.46,500/-. Complainant has not explained as to why he paid Rs.1,07,877/-. The bone of contention is that the Complainant’s deprivation of the package facility. It is the contention of the OP that in case of cashless facility package is not available to any patient and so Complainant’s wife was not provided the cashless facility. Had Complainant’s wife been provided that cashless facility the reasoning of the OP would have been justified. On perusal of the document, it is clear that Complainant paid Rs.88,862/- total cost of the Complainant’s wife’s stay at the OP and her delivering the baby as an expectant mother. The question of depriving the patient from package facility does not appear to be justified.

            OP has taken ground that he made correspondence with the TPA which was not made a party in this complaint. OP has further stated that since it informed the bill amount to the TPA, it was not in a position to provide the package. Such analogy furnished by the OP appears to be vexatious. The clear picture which emerges out of the perusal of the case record is that Complainant has made claim of refund of Rs.42,000/- which is the money which he paid in excess of the maximum package of which he was informed of. Neither of the sides have furnished any explanation that the amount which was charged was of any other package which Complainant opted. OP has not denied that the package varied from Rs.26,500/- to Rs.46,500/-. So, taking into account the maximum package the Complainant appears to be entitled for refund of Rs.42,000/-.

            Here we make it clear that the contract between the insurer and insured is a contract which binds them only and no hospital or nursing home has any right to interfere in that. So far as the interference by TPA is concerned, it also does not confer any right for hospital or nursing home. A TPA is appointed for the benefit of both insurer and insured who is expected to mediate between them and OP cannot make a claim that since the matter was informed to TPA, Complainant is not entitled to the package facility .

            Annexure 2 is a document filed on behalf of the Complainant which reveals that the OP made an endorsement stating that patient did not avail cashless facility. But this does not mean that patient has relinquished the package facility also since insurance company did not provide cashless facility, Complainant was entitled to package facility. It is because providing of package facility is between the patient and the hospital and no where insurance or TPA comes into the picture. Similarly, providing cashless facility is between the insurance company and insured and no where hospital or nursing home comes into the picture.

            In the aforesaid facts and circumstances, we are of the view that Complainant is entitled to refund of Rs.42,000/-.

            Further, Complainant has prayed for compensation of Rs.50,000/- for harassment and another Rs.50,000/- for mental agony. These two categories of compensation cannot be separated. However, we are of the view that if compensation of Rs.30,000/- is provided the object of justice would be served. Similarly, Complainant is entitled for litigation cost of Rs.5,000/- as prayed.

            Hence,

ordered

            CC/117/2016 and the same is allowed on contest. OP is directed to pay Rs.42,000/- to the Complainant within two months of this order, provided original documents are filed in the office of this Forum. In addition, they are directed to pay Rs.35,000/- as compensation and litigation cost within this period. In default, the total amount of Rs.77,000/- shall carry interest @ 10% p.a. from the date of this order.