By Sri. MOHANDASAN.K, PRESIDENT
The case of the complainant is as follows:-
1. The complainant is a pensioner who retired from the police department, government of Kerala. He is part of medisep insurance scheme vide ID No. 1410478 and as per this scheme he is entitled for the benefit of cashless treatment. During the month August 2022 he consulted a doctor due to severe pain to his both legs and then the doctor stated to him that there is issue of blood circulation to the legs and for that treatment is required. Then the complainant examined the hospitals M paneled under the medisep scheme and found that Aster MIMS hospital Calicut is part of this empanelled hospitals. Then he approached the hospital Aster MIMS Calicut and on examination the doctor suggested peripheral angiogram as part of treatment. Then he informed the hospital authorities that he is entitled benefit under medisep scheme and thereby obtaining prior approval he got admitted in the hospital on 19/08/2022 and underwent angiogram test. As per the test result there was block for blood circulation to both legs and suggested angioplasty to both legs and that is to be done through different occasions. The hospital authorities informed to the complainant that only after prior approval he can be admitted in the hospital for the treatment. Moreover an amount of Rs. 9,900/- was alone from the medisep for the angiogram test which he incurred in the hospital.
2. The complainant got information from the medisep desk of the MIMS hospital on 16/09/2022 and he got admitted with hospital and underwent balloon plasty for his left leg. He was discharged on 19/09/2022. At the time of discharge he was issued treatment bill for Rs. 63, 0000/- . Out of the said amount 58,100/- was approved by the medisep and the balance amount Rs.4, 900/- was remitted by the complainant through cheque No. 561848 drawn on state bank of Manjeri branch.
3. On 05/10/2022 he got instruction from the hospital to report and admit again for the angioplasty to his right leg. During this time it was suggested self-expandable stud in addition to balloon plasty. He was treated this time from 05/10/2022 to 07/10/2022 and at the time of discharge he was issued medical bill for Rs. 1,15,506/- . But it was informed only Rs. 54,100/- was allowed as part of medisep scheme and he was directed to pay the balance amount of Rs. 59,406/-. On enquiry by the complainant it was informed that the medisep was not allowed the cost of implant stud Rs. 54,506/- , moreover the angioplasty expense also was allowed after reducing 2,000/- rupees compared to the earlier treatment expense. The hospital authorities informed the complainant that only on remittance of Rs.59, 506/- the discharge procedure could be completed. Hence the complainant managed 50,000/- from the relatives and 9,506/- rupees from his own account and thus the hospital bill was settled.
4. The complainant alleged the offer under medisep scheme was treatment up to 3, 00,000/- rupees per year on collection of Rs. 6000/- per year from the service pension of the complainant. The complainant undergone treatment with prior approval but thereafter the complainant was compelled to incur 59,506/- rupees and thereby he was disgraced among the relatives which cannot be accepted.
5. The complainant thereafter approached the district level medisep grievance cell and the complaint was registered as MG 4822/6/12/2022. Thereafter on 28/04/2023 he was informed that the complaint was disposed holding the complainant is entitled the cost of implant. Thereafter though he waited three months no result was yielded. Then he wrote to the Aster MIMS Calicut stating the facts of the bad experience. But there is no result for the same also.
6. Hence the complainant prayed for the balance treatment expense of Rs .64, 306/- along with compensation and cost.
7. On admission of the complaint notice was issued to the opposite party and on receipt of notice the opposite party entered appearance and filed version. The opposite party denied the entire averments and allegations in the complaint and submitted that the complaint is not maintainable either in law or on facts and is liable to be dismissed with the cost of the opposite party.
8. The opposite party admitted that the complainant is part of the medical insurance scheme for the state employees and pensioners implemented by the government vide policy No. 441200/48/2023/277 for a period from 01/07/2022 to 30/06/2023. But the liability to compensate the complainant is subject to the terms and conditions of the policy is as per the memorandum of understanding executed and signed in between the opposite party and the additional chief secretary, finance department / officer on special duty (finance resources). It is submitted in case of any dispute with respect to medisep policy the claim has to be submitted before the grievance officer, regional office, metro palace, north railway station, Cochin and so the commission has no jurisdiction to try the complaint.
9. The opposite party admitted the fact that complainant was treated twice as impatient in MIMS hospital from 16/09/2022 to 19/09/2022 and from 05/10/2022 to 07/10/2022 peripheral angioplasty to his both legs. The opposite party as per clause 621 of the MOU executed and signed in between the opposite party and the additional chief secretary finance department / officer on special duty (finance resources), since MIMS hospital falls under the II category the opposite party is liable to pay a package of Rs.49, 100/- towards the angioplasty charges, two days bed charges and Rs. 5,000/- towards ICU charges. On receipt of the claim documents on behalf of the complainant the claim was reviewed by the team of panel doctors and in accordance with the opinion of the panel doctors the claim is to be investigated and accordingly they had sanctioned Rs.58, 100/- for the discharge bill dated 19/09/2022 of Rs. 63,000/- issued from the hospital in favor of the complainant and the same was accepted the opposite party and accordingly sanctioned Rs. 58,100/- for the first admission. It is specifically submitted that since MIMS hospital falls under the second category as stated above the opposite party is liable only to pay a package of Rs. 49,100/- towards the angioplasty charges , two days bed charges and Rs. 5,000/- towards ICU charges. In addition to room rent Rs.4, 000/- and thus the total amount was calculated as Rs. 58,100/-. According to them as per the meidsep policy the said amount is the full and final amount which is entitled to the complainant, who is a member of the said policy.
10 The opposite party further submitted that the complainant admitted again on 05/10/2022 for peripheral angioplasty to his left leg and was discharged on 07/10/2022. As per the clause 621 of the above MOU the opposite party is liable to pay a package amount of Rs. 49,000/- towards the angioplasty charges, one day bed charges and Rs.5,000/- towards ICU charges and as part of the data attached to above clause for implant and room rent the opposite party is only liable to pay Rs . 21,000/- towards the implant charges. Hence on receipt of the claim for the second discharge bill dated 07/10/2022 of Rs. 1,15,506/-, which was also reviewed by team of panel doctors of meidsep and they found that no bills or estimate was given by the MIMS hospital with respect of the implants inserted to the leg of the complainant. As per the clause 621 of MOU with respect to the data or implant and room rent, the opposite party is only liable to pay Rs.21, 000/- towards the implant charges. But for the same also either implant bill or the estimate is to be issued from the concerned hospital, which is not produced so far in the above claim. Hence the opposite party has sanctioned Rs. 56,100/- for the second discharge bill without sectioning any amount towards implant charges. The opposite party specifically clarified the sanctioned amount Rs. 56,100/- i.e. Rs. 49,100/- towards package as per clause 621 of MOU, Rs. 5,000/- ICU charges and Rs. 2,000/- as room rent.
11. The opposite party further submitted that on verifying the hospital records of the complainant by the team of panel doctors it was found the complainant was already having complaint of CAD, TVD (Triple vessel disease), CABG, Coronary Artery Bypass Graft) since 01/09/25005 and he was also known case of diabetes mellitus, hyper tension and dyslipidemia and the documents does not reveal when the above said ailments started for him. Hence the submission of the opposite party is that the present condition of peripheral angioplasty to his legs are the result of uncontrollable diabetes and hyper tension , for which also this opposite party should not be made liable to compensate .
12. The opposite party further submitted that the above said both calculations are based upon the clauses annexed in the MOU signed and executed in between the opposite party and the finance department and the medisep policy is promulgated according to the directions of the National Pharmaceutical Authority of India (NPTA). As per the MOU the opposite party can use the implant list and cost suggested by the national health authority as the reference point of medisep policy. Accordingly as per the clause 621 of the MOU the opposite party is liable to pay Rs. 21,000/- towards the cost of the implants, but for which till date no supporting bills were produced by the complainant in the above matter. Hence this opposite party is not at all liable to compensate any amount towards the treatment expenses of the complainant in the matter, the opposite party submitted. The opposite party denied the allegations of deficiency of service and submitted that there is no cause of action against the opposite party. It is submitted the complainant is not entitled for any relief as prayed in the complaint.
13. The complainant and opposite party is filed affidavit and documents. The documents of the complainant marked as Ext. A1 to A26. Ext.A1 is photo copy of medisep card. Ext.A2 is photo copy of hospital consultation fee receipt 15/08/2022. Ext.A3 is consultation OP ticket under medisep scheme dated 15/08/2022. Ext. A4 is copy of discharge summary dated 19/08/2022. Ext.A5 is copy of medical bills from Aster MIMS hospital Calicut dated 19/08/2022. Ext.A6 is copy of discharge summary dated 19/09/2022. Ext.A7 is photo copy of medical bill dated 19/09/2022. Ext.A8 is copy of medisep claim approval for Rs. 58,100/- dated 19/09/2022. Ext.A9 is photo copy of cheque for Rs. 4,900/- dated 21/09/2022.Ext.A10 copy of discharge summary 07/10/2022. Ext.A11 photo copy of medical bill for Rs.1, 15,506/- dated 07/10/2022. Ext.A12 is claim approval statement dated 08/10/2022 for Rs. 56,100/-. Ext.A13 is photo copy of payment receipt dated 07/10/2022 for Rs. 50,000/-. Ext. A14 copy of payment receipt for Rs. 9,406/-. Ext.A15 is copy of letter of approval issued from finance department, government of Kerala dated 14/12/2022. Ext.A16 is copy of complaint submitted by the complainant before the oriental insurance company, Kochi. Ext.A17 is copy of claim acceptance receipt issued from district level complaint processing authority dated 17/01/2023. Ext.A18 is copy of complaint submitted by complainant before the billing section, MIMS hospital, Kozhikode. Ext. A19 is copy of claim approval of Rs. 58,100/- dated 20/09/2022. Ext.A20 is copy of blank cheque in account No.57069368778 SBI, Manjeri Town. Ext.A21 photo copy of blank cheque SBI. Ext. B22 is photo copy of cheque for Rs.490/- dated 21/09/2022. Ext. A23 is photo copy of medical bill For Rs. 1, 15,506/- dated 07/10/2022. Ext.A24 is photo copy of blank cheque issued in favor of MIMS hospital. Ext.A25 is photo copy of blank cheque issued in favor of MIMS hospital. Ext. A26 is photo copy of paper news published by Mathrubhoomi daily dated 06/01/2024. No document produced by the opposite party.
14. Heard complainant and opposite party, perused affidavit and documents. The following points arise for consideration:-
- Whether the complainant is entitled for the insurance claim under medisep scheme?
- Whether there is deficiency in service on the part of the opposite party?
- Relief and cost?
15. Point No.1, 2 and 3
In this complaint there is no dispute that complainant is a beneficiary under medisep insurance scheme. The opposite party also admitted the treatment undergone by the complainant. The contention of the opposite party is that they issued the benefit under the scheme as per the terms and conditions entered between the governments of Kerala vide policy No. 441200/48/2023/277 valid for the period 01/07/2022 to 30/06/2023 and the opposite party. In addition to that the opposite party submitted that the complainant did not furnish bills or estimate given by the MIMS hospital Kozhikode with respect to the implants inserted to the leg of the complainant. According to opposite party clause 621 of the MOU with respect of the data for implant and room rent the opposite party is liable to pay Rs. 21,000/- towards the implant charges. Since the complainant did not produce implant bill or the estimate is to be issued from the concerned hospital the opposite party did not allow the claim of the complainant. Moreover the opposite party contended that the complainant was already having compliance of CAD, TVD, and CABG since 01/09/2005 and the complainant was also a known case of diabetes mellitus, hyper tension and dyslipidemia and the documents does not reveal when the above ailments started for him. Hence the contention is that the present condition of peripheral angioplasty to the legs of complainant are the result of uncontrollable diabetes and hypertension, for which the opposite party should not be made liable to compensate.
16. The Commission have gone through the affidavits of both parties and documents of the complainant. It can be seen that the complainant on verification found the Aster MIMS hospital Calicut is an empaneled hospital under the medisep scheme and thereby approached the hospital for the treatment. On consultation from the hospital the treatment was advised. Thereafter obtaining the sanction for the treatment under the medisep scheme he admitted in the hospital on 16/09/2022 and discharged on 19/09/2022. The hospital issued a medical bill for Rs. 63,000as per Ext. A7 but the opposite party allowed only Rs. 58,100/- . The opposite party contended that as per the terms and condition the opposite party is liable to pay package of Rs. 49,100/- towards the angioplasty charge, 5,000/- rupees towards 2 days bed charges and Rs. 4,000/- for room rent. But the complainant submitted that the empanelled hospital issued the above stated bill for Rs, 63,000/- and so he was made to pay Rs. 4,900/- to settle the hospital bill. There is no dispute regarding the hospital bill Ext. A7. Ext.A7 specifically disclose the three heads i.e. bed charges 4,000/- rupees, clinical support services as Rs.5, 000/- and package as Rs. 54,000/-. Hence there is no sufficient reason to reduce the bill amount from 63,000 to 58,100/-. The complainant is entitled the balance amount Rs. 4,900/-.
17. The complainant admitted again as part of the treatment on 05/10/2022 and he was discharged on 07/10/2022. At the time of second admission he was issued bill for Rs.1, 15,506/- as per Ext. A11. As per Ext. A11 it reveals the bed charges as 2,000/- rupees, the clinical support services as Rs. 5,000/- . The package as Rs. 54,000/- and implant cost as Rs. 54,506/-. But the opposite party paid towards the total amount of Rs. 1,15,506/- as per Ext. A11 Rs. 56,100/-. According to the opposite party the package as per clause 621 of MOU is Rs. 49,100/-, ICU charges is Rs. 5000/- and room rent is only Rs. 2,000/- thus the total amount is 56,100/-. The contention of the opposite party is that the complainant did not produce either the implant bill or the estimate to be issued from the concerned hospital. If at all it is produced they are only liable to pay Rs. 21,000/- towards the implant charges.
18. It is an admitted fact the Aster MIMS hospital Calicut is an empaneled hospital under meidsep scheme. The complainant approached the hospital and with prior approval he undergone treatment. The hospital authorities issued the medical bills Ext.A11 which specifically stated the expense towards implants as Rs. 54,506/-. The documents further reveals the complainant remitted the entire amount to the hospital towards the treatment expense undergone by him under the medisep scheme. If the opposite party is not able to provide the treatment expense under the medisep scheme before the empanelled hospitals it is the responsibility of the opposite party to make aware the medisep card holder about the limit of their liability. Though the opposite party cited the clause 621 of the MOU between the opposite party and the additional chief secretary, finance department / officer on special duty, government of Kerala the opposite party did not produce the document before this Commission. It is also relevant to note that the treated hospital categorically stated the cost of implant and the treatment expenses in the medical bill. So the denial of insurance claim without proper and satisfactory explanation cannot be justified.
19. Moreover in this complaint the complainant approached the additional chief secretary to the government of Kerala seeking permission filing complaint before level II grievance filing system before grievance redressal committer as per Ext A15. Ext. A16 shows the complainant issued notice to the insurance company regarding his grievance. Complainant produced replay received from district level complaint processing committee of medisep. Which reveals “claim പരിശോധിച്ച് അര്ഹമായ ഇംപ്ലാന്റ് തുക കൂടി കക്ഷിക്ക് ഇന്ഷുറന്സ് അനുവദിക്കേണ്ടതാണ്. പരാതി തീര്പ്പാക്കി . The said information is served on the complaint which is dated 28/04/2023. But the complainant did not receive any positive response from the insurance company, the opposite party. Thereafter waiting 5 months the complainant filed the present complaint before this Commission seeking redressal of his grievance .The commission finds there is merit in the complaint and the complainant is entitled the insurance benefit as stated in the complaint.
20. The complainant submitted that he spent altogether 1, 88,406/- rupees for the treatment. But the opposite party allowed only Rs. 1, 24,100/- rupees. Hence he prayed for the balance amount of Rs. 64,306/- rupees. The commission finds the complainant is entitled for the above said amount under the medisep scheme. The complainant further submitted that he was disgraced among the family due to want of money for the treatment at the time of discharge from the hospital. He was compelled to deposit blank cheques before the hospital which resulted mental agony and inconvenience to the complainant. Hence the complainant is entitled a reasonable amount as compensation on that ground. The commission finds Rs. 50,000/- will be reasonable amount as compensation on account of deficiency in service and unfair trade practice and thereby caused inconvenience and hardship to the complainant. The complainant is also entitled Rs.10, 000/- as cost of the proceedings.
In the light of above facts and circumstances, the complaint stands allowed as follows:-
- The opposite party is directed to pay Rs. 64,306/- (Rupees sixty four thousand three hundred and six only) to the complainant towards the treatment expense of the complainant.
- The opposite parties directed to pay Rs. 50,000/- (Rupees fifty thousand only) as compensation on account of deficiency in service and thereby caused inconvenience and hardship to the complainant.
- The opposite party is directed to pay Rs. 10,000/- (Rupees ten thousand only) to the complainant as cost of the proceedings.
The opposite party shall comply this order within one month from the date of receipt of copy of this order, failing which the complainant is entitled interest for the above said entire amount at the rate of 9% per annum from the date of order to till date of payment.
Dated this 30th day of September, 2024.
Mohandasan. K, President
Preethi Sivaraman.C, Member
Mohamed Ismayil.C.V, Member
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1to A26
Ext.A1: Photo copy of medisep card.
Ext.A2: photo copy of hospital consultation fee receipt 15/08/2022.
Ext A3: Consultation OP ticket under medisep scheme dated 15/08/2022.
Ext A4: Copy of discharge summary dated 19/08/2022.
Ext A5: Copy of medical bills from Aster MIMS hospital Calicut dated 19/08/2022.
Ext.A6: Copy of discharge summary dated 19/09/2022.
Ext.A7: Photo copy of medical bill dated 19/09/2022.
Ext A8: Copy of medisep claim approval for Rs. 58,100/- dated 19/09/2022.
Ext A9: Photo copy of cheque for Rs. 4,900/- dated 21/09/2022
Ext A10: Copy of discharge summary 07/10/2022.
Ext.A11: Photo copy of medical bill for Rs.1, 15,506/- dated 07/10/2022.
Ext.A12: Claim approval statement dated 08/10/2022 for Rs. 56,100/-.
Ext A13: Photo copy of payment receipt dated 07/10/2022 for Rs. 50,000/-.
Ext A14: Copy of payment receipt for Rs. 9,406/-.
Ext A15: Copy of letter of approval issued from finance department, government of
Kerala dated 14/12/2022.
Ext.A16: Copy of complaint submitted by the complainant before the oriental insurance
company, Kochi.
Ext.A17: Copy of claim acceptance receipt issued from district level complaint processing
authority dated 17/01/2023.
Ext A18: Copy of complaint submitted by complainant before the billing section MIMS
hospital, Kozhikode.
Ext A19: Copy of claim approval of Rs. 58,100/- dated 20/09/2022.
Ext A20: Copy of blank cheque in account No.57069368778 SBI, Manjeri Town.
Ext.A21: Photo copy of blank cheque SBI.
Ext.A22: Photo copy of cheque for Rs.490/- dated 21/09/2022.
Ext A23: Photo copy of medical bill For Rs. 1, 15,506/- dated 07/10/2022.
Ext A24: Photo copy of blank cheque issued in favour of MIMS hospital.
Ext A25: Photo copy of blank cheque issued in favour of MIMS hospital.
Ext.A26: Photo copy of paper news published by Mathrubhoomi daily dated 06/01/2024. No document produced by the opposite party.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Nil
Mohandasan. K, President
Preethi Sivaraman.C, Member
Mohamed Ismayil.C.V, Member
