Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.397/04.11.2016
Sh. Khushal Chand son of Sh. Hiralal
resident of H. No. 16/897-H, Bapa Nagar,
Hardhian Singh Road, Karol Bagh,
New Delhi-110005 ...Complainant
Versus
OP1 Shree Jeewan Hospital through its Manager/
Director (s) 67/1, New Rohtak Road, Karol Bagh,
New Delhi-110005
OP2 The Oriental Insurance Co. Ltd. through its Manager/
Officer Having its office at : Divisional Office No.2, 16/20,
Ist Floor, W.E.A., near Shastri Park, Padam Singh Road,
Karol Bagh, New Delhi-110005
OP3 M/s. Health India TPA Services Pvt. Ltd.
(through its Manager/Director) Having its office
at : Anand Commercial Company Compound,
103-B, L.B.S. Marg, Gandhi Nagar, Vikroli (West)
Mumbai-40008 …Opposite Parties
Order Reserved on: 10.02.2023
Date of Order: 24.04.2023
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Inder Jeet Singh
ORDER
1.1. (Introduction to case of parties) : Insured/complainant’s minor son, aged about 4-1/2 years, was ill. He was admitted in the hospital of OP1 on 11.09.2016, doctor advised he would be discharged on 12.09.2016. However, despite after treatment as indoor patient, the complainant and his son were compelled by OP1 to stay till 14.09.2016 inside the gallery of hospital till payment of Rs. 10,134/-, being cashless facility, was paid by the Insurer/OP2 and consequently the complainant alleges deficiency of services against OPs and he claims compensation of Rs. 3,00,000/- for their illegal detention, they suffered mental pain and agony and also their status/image was lowered in the community/biradari. Complainant also claims interest at the rate of 24% pa apart from litigation costs.
1.2: OP1/hospital opposed the complaint, in nutshell, the entire allegations are against insurer/OP2 and OP3 and there is no iota of allegations of deficiency of medical services against OP1. Moreover, it was complainant, who requested OP1 to await till final approval from OP3 in receiving the payment, the complainant himself kept on delay of discharging his child.
1.3: The OP2/Insurer also opposed the complaint that information was received from the hospital/ OP1 on 12.09.2016 and prompt payment was issued on 13.09.2016. There is no deficiency on the part of OP2.
1.4. OP3/TPA has not appeared nor filed any reply, it was proceeded ex-parte on 13.02.2017
2.1 (Case of complainant ) : Succinctly, the complainant availed Family Insurance Policy (cashless) / Family Floater policy no. 211200/48/2017/39 of OP2, for sum insured of Rs. 3,00,000/- under silver plan valid from 15.04.2016 to mid night of 14.04.2017. On 11.09.2016 complainant’s son was admitted in hospital of OP1 due to his illness, his son was treated by the doctors of OP1 and it was assured that his son will be discharged on 12.09.2016. On 12.09.2016, the complainant requested OP1 to issue discharge slip, however, it was refused on the pretext that until OP2 and OP3 pay medical bills amount, discharge slip would not be issued. The complainant along with his son was not permitted to move outside the hospital, they were compelled to stay in the gallery of hospital till 14.09.2016, when OP2 and OP3 made the payment of treatment of Rs. 10,134/-.
2.2: It was a cashless facility/treatment. After the discharge, the complainant’s request was not listened by the OP1, rather he was threaten for dire consequences and there is also negligence on the part of OP2 and OP3, who failed to make the payment within time. The forceful detention of complainant and his son by the OP1, caused undue harassment and mental pain, apart from it was illegal and against the law. It has lowered the social status of complainant in the eyes of others & bradari/community. The complainant had also served legal notice dated 29.09.2016 on the opposite parties but they failed to reply or comply the same. That is why this complaint.
2.3. The complaint is accompanying with the record of legal notice along with service report, aadhar card, insurance policy, email, record of admission, medical bill, discharge summary, final bill and authorization letter of TPA to the hospital.
3.1 (Case of OP1) : The OP1 opposed the complaint on three counts- firstly, the entire grievances are against OP2 and OP3 and not against OP1, secondly, there is no allegations of deficiency of medical services nor it is so stated in the complaint, thirdly, it was complainant himself requested to await after 12.09.2016 till final approval from OP3 with regard to payment of bills raised by the OP1, thus either because of complainant's own acts option to await approval to delay the discharge or otherwise because of delay on the part of OP2 and OP3 to release the amount. No legal notice was received by the OP1. Thus, complaint is liable to be dismissed.
The OP1 relies upon the documents of email etc. in support of its contentions.
3.2: (Case of OP2): Neither there is any deficiency of service on the part of OP2 nor any cause of action against it to allow the complaint. The OP2 acted promptly as information was received on 12.09.2016 from OP1 and payment was issued on 13.09.2016, as the claim of cashless was processed forthwith. There is no harassment on the part of OP2, the legal notice was also replied by it. The complaint is liable to be dismissed. The OP2 relies upon record of emails exchanged between the OP1 and OP3.
4.1 (Evidence) : Complainant Shri Khushal Chand filed his detailed affidavit of evidence coupled with the documentary record filed with the complaint, it is on the pattern of complaint.
4.2: OP1 filed affidavit of Dr. Vijay Sabharwal, Chairman of OP1 and his affidavit is on the lines of reply.
4.3. OP2 led its evidence by filing affidavit of Ms. Mandakini Baladhi, Divisional Manager and it is also on the lines of reply, coupled with documentary record of email exchanged.
5.1 (Submission of Parties) : The complainant, the OP1 and OP2 filed their respective written arguments, which are replica of their case already stated. Moreover, Sh. Ankur Gupta, Advocate for complainant, Sh. Akash Saini, Advocate for OP1 and Ms. Sandhya, Advocate for OP2 have also made their respective oral submission.
5.2: The written contentions and oral submissions need not to be mentioned here, as the matrix of cases of the parties, already stated, are the bone of contentions, the same will be referred while appreciating their contentions. Moreover, there are documentary records, which also depicts relevant dates and timings, which will resolve the controversy, therefore, the same will also be referred at appropriate stage. However, the complainant relies upon Devesh Singh Chauhan vs State and ors. MANU/DE/1348/2017, wherein it was held that merely because the dues of the hospital treating the patient are outstanding, that certainly cannot be a reason to withhold the release of the patient. Similarly, OP2 also contended in arguments that OP1/hospital did not provide required information to OP3/ TPA in time, it cannot be construed delay or hardship on the part of OP2.
6.1 (Findings) : The rival contentions of both the sides are considered, apart from adverse plea of OP1 and OP2, keeping in view the documentary record as well as other facts narrated orally in the form of affidavit. Some of the facts are not disputed about the relationship of the complainant as insured and of OP2 of Insurer, OP1 is hospital where complainant's son Master Vivan was treated as indoor patient, after his admission on 11.02.2016. But the other circumstances are disputed by the parties.
6.2: After taking stock of totality of circumstances and analyzing the documentary records, the following conclusions are drawn:-
(i) The discharge summary is composite of bundle of facts and figures viz date/time of admission is 11.09.2016 - 08:30am, date/time of discharge 12.09.2016 - 12:10pm, final bill and its preparation is at 14.09.2018 - 12:41pm and signature of complainant on that billing is of 14.09.2016 at 12:45pm (pages 52, 53-54 of paper book). The discharge summary culls out that complainant’s son was admitted on 11.09.2016 and his son was discharged on 12.09.2016 but the billing was done on 14.09.2016 after receipt of payment;
(ii) as per patient admission form , the name of complainant’s son is Master Vivaan Moriya, his date of birth is 24.04.2012 and admission was on 11.09.2016 at 08:30am, and it also reflects date of discharge 12.09.2016 (page 36 of the paper-book);
(iii) there was pre-authorized request form on 12.09.2016 at 01:51pm being correspondence between OP1 and OP3, then further request was at 04:18pm between them followed by another correspondence at 04:57 pm (page no. 24-26 of the paper-book) which corresponds with the email documentary evidence Exh. OPW-1/1 (being part of evidence of OP2);
(iv) there is further correspondence on 13.09.2016 at 12:00 pm, at 02:58pm, at 03:02am, at 04:02pm and Reminder No- 10 at 07:30 pm (Part of Exh. OPW1/1 colly.) between the OP1 and OP3/TPA of OP2. By reading the series of documents, it is abundantly clear that e-mails were exchanged for cashless facility as well as it was very much clear that patient was indoor patient & discharge was on 12.09.2016; it was not a case of lodging of claim after payment by complainant after discharge by the complainant,
(v) there was a final approval on 13.09.2016 at 08:56pm of payment of the bills by OP3 and thereafter discharge summary along with final bill was prepared (at page no. 52-54), and the timings of preparing of the final bills are 12:41pm of 14.09.2016 and it was signed by the complainant on 14.09.2016 at 12:45pm;
(vi) the OP1 took the plea that complainant himself opted to stay in the hospital or got delayed the discharge of his son, whereas on the other side complainant has grievances that he along with patient/minor son was detained in the gallery of the hospital; however, the circumstances are not leaning towards the OP1, particularly had there been position like to opt to stay in the hospital by complainant, the patient would have continue on the same ward and bed but record is that patient was discharged on 12.09.2016 at 2:10pm (page 53 of paper-book). The billings were also upto 12.09.2016. It is also case of OP1 that the complainant opted for delay discharge, it is admitted position that complainant was physically in the hospital, however, OP1 failed to prove that complainant was there voluntarily. The complainant has specifically alleged that he was threatened as well as he alongwith minor son was forcibly detained. Would any prudent person opt to not keep and stay recently recovered child in gallery of hospital?
(vii) at the time of discharge of indoor patient, a guard slip is issued that too after clearance of bills, that material document has not been produced by OP1 that the complainant along-with his son was physical relieved from on 12.09.2016. There is another additional information request (page 37 of paper-book) being e-mail correspondence between OP1 and OP3, the timings of this email is of 03:01:52am 13.09.2016, also showing that patient was admitted on 11.09.2019 and corresponding column [date of admission -in box in right side], the date of discharge as 14.09.2016 ( the day of 14.09.2016 is yet to be arrived). It clearly establish that the child patient was indoor patient till 12.09.2016 and continue to be under control of OP1, even when this email was exchanged. Later, billings raised were also upto 12.09.2016, payment of bills was received on 13.09.2016, final bill was prepared on 14.09.2016, discharge summary alongwith copy of final bill was also handed over to complainant on 14.02.2016 at 2:45pm. This proves the complainant and his son were permitted to make exit after 2:41pm on 14.02.2016.
(viii) the date of billing as well as physical discharge on 14.09.2016 clearly establish that the complainant along with his son were physically in the hospital and they were permitted to leave after payment of bills by the OP2;
(ix) it is abundantly clear from the final approval letter of 13.09.2016 that it was 08:56 pm that OP3 approved the bill and then on 14.09.2016 after receipt of bill amount of Rs. 10,134/-, the final bill was issued along with the discharge summary and thereafter the complainant along with his patient son were permitted to leave the hospital;
(x) the OP2 and OP3 had information after admission of complainant’s son in the hospital, however, the final bill was approved on 13.09.2016 at 08:56 pm and amount was remitted on 14.09.2016 at 12:41pm, which result into restrain of the complainant and his son by OP1 in the hospital. OP2 took defence in final hearing that OP1 failed to provide required information in time to OP3/TPA, this gives glimpses that OP2 and OP3 had communications and on that basis OP2 making this assertion, however, (a) OP2 could not account, which information was sought and not provided in time, (b) how much delay is there, if so (c) there is record of repeated emails with attachments exchanged between OP1 and OP3, then what was lacking and (d) it also becomes admitted case of OP2 that delay had happed, for which complainant cannot be made to suffer;
(xi) it is never the case of complainant against OP1 that there was deficiency of medical services, but a camouflage being tried to be created by the OP1 of its own in its reply, since the complainant had grievances that it was cashless facilities and let he and his son may be not detained in the hospital under threatened and forcibly. The ratio of law laid down in Devesh Singh Chauhan (supra) applies to situation in hand; and
(xii) the conclusion drawn in sub-paragraphs (i) to (xi) above clearly establishes that there is deficiency of services on the part of OP1 by detaining the patient Master Vivaan, after his discharge and his father was also compelled to be restrained here being an attendant to patient/minor son. OP1 is liable towards complainant for such negligence and deficiency in services. It was also not medically safe to recently discharged patient to keep/detain in gallery of hospital being risk prone spot . It would not give any benefit to OP1, if there was no police report for their detention, since information to police is not a condition precedent to substitute the factual position of their detention, which is other emerging from the circumstances and documents of emails.
Similarly, had the final approval been given in time by the OP1 through OP3, the complainant’s son would have been relieved forthwith on 12.09.2016, therefore, there is also deficiency of services on the part of OP2 and OP3. OP2 took stand in final arguments that there was delay on the part of OP1 to given required information to OP3, it has not been explained as to what information was not provided or how much delay is there, since there are repeated e-mails and reminders too. This also makes out admission on the part of OP2, that there was delay in the approval amount. However, OP3 is just a service provider to OP2, the OP2 is liable towards the complainant for such deficiency in services.
6.3: In view of the conclusion drawn in sub-paragraph 6.2, above, that OP1 as well as OP2 are responsible for deficiency of services. They are liable to compensate the complainant. However, it is also manifest that OP1 had detained the complainant along-with his minor son/patient aged about 4-1/2 years, immediately after treatment as indoor patient, they were detained for period timing of discharge 2:10pm/12.09.2016 to physical discharge at 2:45pm/14.9.2016 (page 53-54 & 37 of paper-book). On the other side, OP3 has made final approval of bills on 13.09.2016 at 8:56pm (page 35 of paper-book) on the basis of which final bill (page 53-54) was prepared.
To say, there is separate roles and attribute of deficiency of services & negligence of OP1 and deficiency of services by OP2, but there is composite adverse impact, it is complainant alongwith his son suffered harassment, inconvenience, agony, although, there is nothing in evidence that OP2 had asked OP1 to detain the complainant alongwith the patient in the hospital of OP1. But considering the role of each of them, the amount of compensation is to be determined. But the complainant has claimed consolidated amount of compensation of Rs.3,00,000/- against OPs without disclosing his own source of income, annual income, social status etc. in his evidence. Simultaneously, the complainant and his minor son faced inconvenience, harassment, agony and risk of un-known health perils. while remaining exposed to hospital surroundings for about two days continuously after date/time of discharge. For this, the complainant along-with son are entitled for general damages of Rs.75,000/- against OP1 and OP2 to meet both ends.
Considering the circumstances attributable to OP1 & OP2, the OP1 is held liable to damages/compensation of Rs.50,000/- and OP2 is held liable to pay damages/compensation of Rs.25,000/- to the complainant and for his child.
7. Accordingly, the complaint is allowed in favour of complainant and against the OP1 to pay damages/compensation of Rs.50,000/- within 30 days from the date of receipt of this order. Similarly, the complaint is also allowed in favour of complainant and against the OP2 to pay damages/compensation of Rs.25,000/-. The amounts are payable within 30 days from the date of receipt of this order.
In case the OPs do not pay the whole or part amount within 30 days from the receipt of this Order, then OPs will be liable to pay simple interest at the rate of 7% pa on unpaid amounts, from the date of filing of the complaint till realization of the amount. The costs is determined as Rs.10,000/- payable equally by OP1 and OP2. There is no order against OP2's service provider OP3/TPA.
8. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
9: Announced on this 24th April 2023 [वैशाख 04, साका 1944].
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
