SMT.MOLYKUTTY MATHEW : MEMBER

     This is a  complaint filed by the complainant  U/S 35 of the Consumer Protection Act 2019 for an order directing the OPs to pay Rs.23,600/- as the  claim amount to the complainant  along with Rs.5000/- as the compensation for mental agony caused to the complainant and Rs.5000/- as litigation  cost for the  deficiency of service and unfair trade practice  on the part of OPs.

  The brief of the complaint :

    The complainant is a pensioner and he is the member of medisep scheme in Family Health  plan insurance.  On 13/10/2023 the complainant arrived  at 3^rd OP hospital with symptoms of abdominal pain, vomiting, severe weakness.  The complainant evaluated  and vitals monitored by Dr.Thaslim K.Arif (MBBS,MD) the general medicine practitioner.  The complainant was showing severe weakness and vomiting and also with the known history of Tuberculosis(since August 2023) .  The complainant was advised for an admission  observation to rule out “ Drug induced hepatitis” also advised for clinical evaluation and the complainant was under went for clinical test of Hb,CB,LFT,HB Sag, HIVI and 2, Sodium, potassium, HCV card, SGOT, SGPT, total Bilirubin, creatine total protein, Albumin etc, under observation admission the complainant was given oral medication and IV fluids to manage vomiting and weakness.  After reviewing the test result diagnosed with pulmonary Tuberculosis with Drugs induced Gastritis Hypertension.  The clinical practitioner suspected a chance for drug induced hepatitis and to rule out this liver function test has been done.  In order to rule out the causes and bring the complainant to  hemodynamically stable  advised for 2 days of admission, later the complainant was discharged.  Then the complainant availed the treatment for any illness medisep is working on prefixed package for treatment.  Then 3^rd OP hospital insurance desk has taken proper approval for treatment on the day of admission as per the medisep procedures and pre auth has been approved.  On the day of discharge  all treatment records submitted and claim initiated as per package approved by medisep for the  amount of Rs.23,600/-.  But  1^st OP rejected the claim and stating that (a) the condition of the patient during hospitalization was completely normal(b) the patient was mainly on oral medication and ( c) the provided treatment can be performed as on OPD basis.   So denying the actual treatment expenses to the complainant  by the  1^st OP without any valid reason.  So the act  of 1^st OP the complainant caused much mental  agony and financial loss. So there is deficiency of service and unfair trade practice on the part of OPs.  Hence the complaint.

        After filing this complaint notice issued to all OPs. All OPs received  the notice  and appeared before the commission  and filed their written version. The 1^st OP contended that the complainant filed  complaint claiming benefit under the medisep scheme, the beneficiary must completed the 3 tier grievance mechanism considering the  question of maintainability.  Under Sec.100 of Consumer Protection Act the complainant has to power to conduct the  case before this commission.  Moreover, the 1^st OP submits that the report received from FHPL TPA is “ the patient was admitted to the hospital with the chief complaints of abdominal pain, vomiting, severe weakness.  All investigation reports  are within a normal limits.  Patient was on an oral medications as per date 13/10/2023.  All vitals are stable.  As per the TPA report, it is clear that the ailment could have been treated on OP(out patient) basis(hospitalization was not necessary) the claim rejected by medisep stating the reasons  the condition of the patient during hospitalization was completely normal, the patient was mainly on oral medication and the provided treatment can be performed as on OPD basis. So there is no deficiency  of service on the part of  1^st OP and  the complaint may be dismissed.

   2^nd OP contended that the insurer ie, Oriental Insurance company Ltd shall decide on the acceptance or rejection of any claim.  Hence Government has no role in acceptance / rejection of individual claim.

   3^rd OP contended that the complainant was advised for an admission  observation under  General medicine  Department to rule out  Drug induced hepatitis.  After reviewing the test result diagnosed with pulmonary Tuberculosis with Drugs induced Gastritis Hypertension.  3^rd OP is a reputed hospital with all facilities to diagnose and treat have monitored the vitals  and conditions of patient or arrival and the  complainant was required an admission due to severe weakness and vomiting, the complainant was not only given oral medication but also provided IV fluid for speedy recovery, detailed evaluation and test shows patient required a minimum period of admission to become a symptomatically better condition and all the allegation mentioned by medisep is not acceptable.

      On the basis of the rival contentions by the pleadings the following  issues  were framed for consideration.

1. Whether  the complaint is maintainable?
2. Whether there is  any deficiency of service   on the part of the opposite parties?
3. Whether the complainant is entitled for any relief?
4. Relief and cost.

     The evidence on merits of the oral testimony of PW1 and  Exts. A1 to A4 marked.  On OP’s side DW1 was examined and no documents marked .

Issue No.1: 

  As per IA 68/2024 1^st OP raised an issue of maintainability of the complaint against the 1^st OP as the preliminary issue.  The claiming  benefit under the medisep scheme the beneficiary must complete /undergo the 3 tier grievance mechanism.  Whereas  in this  case the complainant/beneficiary has not completed the 3 tier grievance mechanism as prescribed for the medisep scheme.  OP’s petition in IA 68/2024 is dismissed by the commission as per Sec.100 of  the Consumer Protection Act 2019 and the  present complaint is maintainable.  So the  issue No.1 found in favour of the complainant.

Issue No.2: 

         The  Complainant  adduced evidence before the commission by submitting  his chief affidavit in lieu of  his chief examination to the tune of the pleadings in the complaint and denying the  contentions in the version.  He was cross examined as PW1 by  OPs 1&3. The documents Exts.A1 to A4 were marked.  According to the complainant Exts.A1 is the  claim form.  Ext.A2 is the discharge summary.  It clearly shows that 3^rd OP’s hospital the complainant has admitted on13/10/2023 and discharged on 16/10/2023.  Ext.A3(series)  is the medical bills for an amount of Rs.23,600/-.  So it clearly shows that the complainant is under admission in 3^rd OP hospital and he incurred an amount of Rs.23,600/- as the medical expenses.  Ext.A4 is the copy of medisep card.  So it clearly shows that the ID No/ Medisep card No.1103053 bears to the complainant.  Since the 1^st OP is denied the re-imbursement .  In the evidence of PW1 who clearly states that Ext.A3(series) ൽ IV fluid, injection etc doctor  നിർദ്ദേശിച്ചിട്ടുണ്ട്? ശരിയാണ്. IV fluid വീട്ടിൽ വച്ച് നല്കാനുള്ള സൌകര്യം ഉണ്ടോ? ഇല്ല. Ext.A3(series) ൽ പറഞ്ഞിരിക്കുന്ന പല മരുന്നുകളും injectonആയിട്ടാണ് നൽകേണ്ടത്? ശരിയാണ്. നിങ്ങളുടെ  claim അനുവദിക്കാനോ,നിരസിക്കാനോ  ഉള്ള അധികാരംOP.NO.3 യ്ക്ക് ഇല്ലെന്ന്പറയുന്നു? ശരിയാണ്. OP.NO.3യ്ക്കെതിരെ ഒരു സേവന വീഴ്ചയും നിങ്ങൾ ആരോപിക്കുന്നില്ല ? ഇല്ല. So OP.NO.3’s liability  may be exonerated.  Moreover, he states that “ Medisep പ്രകാരം നിങ്ങൾ ആർക്കാണ് ആദ്യം പരാതി നല്കിയത്? ഞാൻ OP.NO.3യ്ക്കാണ് പരാതി നല്കിയത്. OP.NO.1 നിങ്ങളുടെ claim നിരസിച്ചത് OP.NO.3യുടെ റിപ്പോർട്ടിന്ർറെ അടിസ്ഥാനത്തിലാണെന്ന് പറയുന്നു? ശരിയല്ല. Moreover, in the  evidence of DW1 who clearly deposed that”  ആവശ്യമായ എല്ലാരേഖകളും OP1 companyയിൽ ഹാജരാക്കിയിട്ടുണ്ട്? ഉണ്ട്. Patient നെ admit ചെയ്യണമോ വേണ്ടയോ എന്ന് തീരുമാനിക്കാനുള്ള അധികാരം  ഡോക്ടർക്കാണ്? അതെ.   So 1^st OP is rejected the re-imbursement claim.  The  act of 1^st OP the complainant  caused much mental agony and financial loss.  So there is deficiency of service and unfair trade practice on the part of 1^st OP.  So  the liability of  OPs 2&3 may be  exonerated.  Hence the  issue No.2 is found in favour of the complainant and answered accordingly.

Issue No.3&4:

    As discussed above the 1^st OP is not ready to  compensate the complainant’s grievance. The complainant produced Exts.A1 to A4  which clearly shows that who is the  medisep member and allowed the claim as per the  medisep scheme.  The complainant had admitted the 3^rd OP hospital on 13/10/2023 and discharged on 16/10/2023.  As per the direction of  3^rd OP hospital’s doctor Mr.Thaslim.K.Arif, the complainant treated there and  paid an amount of Rs.23,600/- as the  medical expenses incurred in the hospital.  But  1^st OP is  rejected the claim. So the  act of 1^st OP the complainant  caused much mental agony and strain. The  1^st OP is  directly bound  to  redressal the grievance caused to the complainant.  Therefore, we hold that the  1^st OP is directed  to  pay the claim  amount of  Rs.23,600/-  to the complainant along with Rs.4,000/- as compensation for mental agony caused to the complainant and Rs.3,000/-as litigation cost . Thus issue No.3&4 are also accordingly answered. 

    In the result the complaint is allowed in part  directing the 1^st opposite party to pay the claim  amount of  Rs.23,600/-  to the complainant along with Rs.4,000/- as compensation for mental agony caused to the complainant and Rs.3,000/-as litigation cost  within  30 days of  receipt  of this order. In default the amount of Rs.23,600/- carries 12% interest per annum from the date of order till realization.  Failing which the complainant is at liberty to execute the order as  per the  provisions  of Consumer Protection Act 2019.

Exts:

A1- Claim form

A2- Discharge summary

A3(series)- Medical bills

A4- Medisep ID card

PW1-Kasim.P.H- complainant

DW1-Vishnu Prasad.P.K- witness of OP

Sd/                                                   Sd/                                                     Sd/

PRESIDENT                                             MEMBER                                               MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva                                                                                                

                                                                  /Forwarded by Order/

                                                                      ASSISTANT REGISTRAR