Complaint filed on: 05-09-2022.
Disposed on: 20-07-2023
BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, TUMAKURU
DATED THIS THE 20th DAY OF JULY, 2023
PRESENT
SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT
SRI.KUMARA.N, B.Sc. (Agri), LLB., MBA., MEMBER
SMT.NIVEDITA RAVISH, B.A., LLB. (Spl)., LADY MEMBER
CC.No.131/2022
Sri,Anilkumar .K
Anil Niwas, Near Raja Clay Works,
Siddhartha Nagar Post, Heggere,
Tumkur, Karnataka-572 107.
……………….Complainant/s
(By Smt. Sarita, GPA holder.,)
V/s
Shridevi Institute of Medical
Sciences and Research Hospital,
NH-4, Sira road, Tumkur
Tumakuru, karnataka.
……………….Opposite Party/s
(By Sri. K.P.Manju Prakash, Adv.,)
: ORDER:
BY SRI.KUMARA.N., MEMBER
The complainant has filed this complaint against the OP U/s 35 of the Consumer Protection Act alleging deficiency in service against the OP and prays to grant compensation for the fear and worry which the complainant had to undergo on account of not being able to avail insurance and prays to direct the OP to reimburse the amount of Rs 118989.00 paid by the complainant.
2. In this case opposite party was / is Shridevi institute of medical Sciences and Research Hospital, NH-4, Sira road, Tumkur Tumakuru, Karnataka. herein after called as OP / OP hospital.
- It is the case of the complainant that the complainant went to the OP Hospital on 4th September 2020 with the complaints of fever and cough which was later diagnosed to be COVID and therefore complainant continued his treatment by admitting to the said hospital from 04-09-2020 and discharged on 16-09-2020. It is further contended that due to fear of COVID-19, the complainant agreed to whatever claims the OP hospital made regarding bed availability and agreed to whatever charges, the OP hospital claimed. The complainant further contended that due to the bill crossing his financial capacity, he obtained Abark scheme, but the said scheme covers only a part of the complainant’s total bill amount and the complainant paid Rs.1,18,989/- including medicines out of his own pocket.
The complainant further submitted that the discharge summary and bills given by the OP Hospital did not have any signature and seal.Hence, the complainant requested the OP Hospital authorities in the month of September 2010 to provide him with the original copies so that he can avail insurance, but the OP hospital authorities denied his request and they were not ready to provide a Bills with signature and seal on the documents, which were available with the complainant.It is further submitted that when the OP hospital has charged him amounts for his hospital treatment, it is the duty of the hospital to provide him bills and original documents for his purposes which the OP has grossly failed and this act of the OP caused losses to the complainant as he has been unable to claim insurance on account of the lack of original documents.Hence, there is a deficiency of service on the part of OP.In spite of requests, the OP did not give original documents and bills and hence without any alternative, the complainant filed this complaint with a prayer to direct the OP to pay the losses to the complainant to an amount of Rs.1,18,989/- which is the actual amount paid to the OP Hospital and also for compensation for fear and worry and also prays that the amount paid by the petitioner to the hospital authorities be reimbursed to him as he has been unable to claim any insurance on account of the hospital not providing the original documents and further also requests the Hon’ble Commission to grant appropriate compensation for the fear and tension which the complainant had undergone along with costs of pursuing the present complaint.
- After the complaint registered, notice was served to the OP. The OP counsel appeared and contended that the complainant was admitted to the OP hospital on 04.09.2020 on the history of cough, fever and cold which was later confirmed COVID pneumonia, he was admitted under ESI (Employees State Insurance Scheme) and he discharged on 06.09.2020 and further the complainant was admitted on 07.09.2020 because he got referral letter from District Hospital to get treatment under Ayushman Bharath Arogya Karnataka Scheme for COVID, the complainant has not paid any amount for this duration and the complainant was treated for COVID and discharged on 16.09.2020 and follow-up discharge summary along with treatment details was advised and further the OP hospital authorities as per the AB-Ark rules have sent the original case file, records, discharge summary bills and all relevant documents to AB-Ark portal for final settlement, initial approval was given by AB-Ark was Rs.85,000/- for 10 days from 07.9.2020 to 16.09.2020 COVID ICU without ventilator, later on final settlement given by AB-Ark for the complainant was on Rs.52,000/-. They have sent the original documents to Ab-ark as per the scheme. Hence, there is no deficiency of service on the part of OP. The complaint filed by the complainant is false, frivolous and vexatious, as such the same is liable to be dismissed. On these among other grounds, the OP denied all other allegations made in the complaint by the complainant and prays to dismiss the complaint.
- On 23-01-2023, the GPA holder of the complainant filed IA u/s 38(9)(C) of CP act 2019, with prayer of direct, the OP to produce and furnish the original bills and discharge summery of the complainant to the complainant, after hearing both the side, this commission decided to pass the order on IA that , it may go along with the main order.
- The complainant has filed his affidavit evidence. The complainant has marked the documents at Ex.R1 to R14 instead of Ex.P1 to P14. Dr.Raman Hulinayakar, Doctor and Director has filed his affidavit evidence on behalf of OP. The OP has marked the documents produced by them at Ex.R1 & R2.
- . We have heard the arguments of counsel for OP. The GPA holder of complainant filed written arguments of the complainant and submitted that their written argument is taken as oral arguments.
8. The points that would arise for our consideration are:-
- Whether complainant proves the deficiency in service on the part of OP?
- Is complainant entitled to the reliefs sought for?
9. Our findings on the aforesaid points are as follows:
Point No.1: Partly in the Affirmative
Point No.2: Partly Affirmative to the below
:R E A S O N S:
Point Nos.(1) & (2):-
10. The GPA holder of the complainant, in her written brief, submitted that, the complainant admitted under AB ArK scheme, to gain financial benefits such as cashless treatment, but the act of OP made the complainant to suffer without giving correct picture of, what’s the total cost of treatment, AB ArK scheme benefits taken by the OP for the treatment given to the complainant etc. Without clear-cut message, the OP acted and not provided original bills and documents to the complainant for the claim of insurance. The OP not given medical records of the complainant that the OP treated in its hospital, it’s a right of the complainant, which leads to deficiency on the part of OP, and prayed to allow the case and award compensation. The GPA holder of the complainant & complainant filed documents as Ex.P1/SBI Passbook of Mr. Venugopalan .K. Ex.P2/Sacred Heart Bank Passbook of Mr.Venugopalan .K., Ex.P3/Photo of bill sheet, Ex.P4/receipt of payments made on dates 12.09.20 and 16.09.20 to OP Hospital, Ex.P5/receipts of payments made on different dates to OP hospital pharmacy, Ex.P6/Pharmacy return bill/receipt dated:16.09.2020, Ex.P7/receipt dated:05.09.2020 for Covid test payment, Ex.R8/Bank statement of Ms Anuthara Kathirottukavil, Ex.P9/Whatsapp Chat printout, Ex.P10/Print of the final bill and discharge summary, Ex.P11/request letter to OP hospital dated:01.09.2021, Ex.P12/Photo of discharge summary, Ex.P13/complaint correspondence to ESI.
11. The OP counsel argued that, the complainant admitted to the OP hospital on 04.09.2020 due to confirmed COVID pneumonia, under ESI (Employees State Insurance Scheme) and discharged on 06.09.2020 and further the complainant was admitted on 07.09.2020, because he got referral letter from the District Hospital to get treatment under Ayushman Bharath Arogya Karnataka Scheme for COVID, after the treatment the complainant discharged on 16.09.2020, and the complainant not paid any amount to the OP for this treatment, as referral case from the District Hospital to get treatment under Ayushman Bharath Arogya Karnataka Scheme for COVID, 19,the OP processed the bills and other documents submitted to the AB-Ark authority for the claim.. When the complainant asked for the original bills for claim insurance, same bills cannot be given, since the bills submitted to the AB-Ark authority. The OP counsel prays to dismiss the case against the OP and produced documents as Ex.R1/Memorandum of understanding between Suvarna Arogya Suraksha Trust and OP and Ex.R2/Government of Karnataka, Notification dated:23.06.2020.
12. Ayushman Bharat – Arogya Karnataka Scheme; Arogya Karnataka" was introduced by Government of Karnataka on 2.3.2018, with the goal of providing Universal Health Coverage to all residents of the State. The Government of India later introduced Ayushman Bharat. Since both Arogya Karnataka and Ayushman Bharat schemes have the same goal, scope and similar modalities, both the schemes were integrated under a co-branded name called "Ayushman Bharat-Arogya Karnataka" and is being implemented in an Assurance Mode from October 30, 2018.
(1)Eligibility
- Basic Sum Assured is Rs. 5,00,000/- per Family, per annum for "Eligible Households (BPL)" and RSBY enrolled beneficiaries.
- For those that do not come under the "Eligible Household" as defined under the NFSA 2013 or are not enrolled RSBY beneficiaries, the sum assured is 30% of the package rate up to Rs.1.5 lakh per family per annum on co-payment basis.
(2)Benefit packages; The integrated scheme covers Simple Secondary, Complex Secondary, Tertiary & Emergency Procedures. Primary treatments and simple secondary procedures will be limited to PHIs only. Complex Secondary procedures, Tertiary procedures and Emergency procedures will be performed in PHIs and empanelled Private hospitals. Complex secondary procedures and tertiary procedures require referral from PHIs. For emergency procedures, patients can directly go to the empanelled hospitals of their choice and avail treatment without referral.
(3) AB-ArK Card;Under the Ayushman Bharat- Arogya Karnataka scheme the enrolment card called AB-ArK Card is provided to the patient at the PHIs on payment of a fee of Rs.10/- in A-4 size paper. AB-ArK cards will be issued at Citizen Service centers, B1 and K1 centers, at a cost of Rs.10/- in A-4 size paper and plastic card at a cost of Rs.35/- .
(4) Fund Sharing Pattern; Government of India will provide funding of 60% and Government of Karnataka will also bear the 40% of the expenditure incurred of the expenditure incurred for beneficiaries.
(5) How to avail the scheme;
- Patients should first go to the nearest Public Health Institutions (PHIs) with their Adhaar Card and Food Card.
- They should get enrolled in the scheme and get their AB-Ark Card.
- Get diagnosis from the same PHI
- If the PHI has capacity to treat the disease, that the patient is suffering from treatment will be provided in the same hospital
- If the PHI has no capacity or capability to treat the disease the patient will be given a referral letter and he will be able to get treatment in any private or government empanelled hospitals of his choice.
- In case of emergency treatments patient can go directly to any government and private empanelled hospitals without referral.
(6) Use of AB ArK card; Beneficiaries can use this card to gain financial benefits such as cashless treatment at any public or private hospital in the state that comes under this initiative.
(7) Benefits of ayushman Bharat for APL card holders; The benefit limit for General Patient shall be 30% of Government package rates, with overall annual limit of INR 1.50 lakh per family per year on a co-payment basis.
(8) Benefit of ayushman card for BPL; Financial assistance up to INR 5 lakh per annum will be provided for specified simple secondary care, complex secondary healthcare treatment, tertiary healthcare and emergency healthcare to a family that comes under the definition of "Eligible Patients".
13. MEDICAL COUNCIL OF INDIA GUIDELINES ON MEDICAL RECORDS; The issue of medical record keeping has been addressed in the Medical Council of India Regulations 2002 guidelines answering many questions regarding medical records. The important issues that have been addressed are as follows:
- Maintain indoor records in a standard proforma for 3 years from commencement of treatment (Section 1.3.1 and Appendix 3).
- Request for medical records by patient or authorized attendant should be acknowledged and documents issued within 72 hours (Section 1.3.2).
- Maintain a register of certificates with the full details of medical certificates issued with at least one identification mark of the patient and his signature (Section 1.3.3).
- Efforts should be made to computerize medical records for quick retrieval (Section 1.3.4).
14. Section 2(47) of the Consumer Protection Act, 2019 defines the term
‘Unfair trade practices’ which include:
- Manufacturing spurious goods or providing defective services.
- Not issuing cash memos or bills for the goods purchased or services rendered.
- Refusing to take back or withdraw the goods or services and not refunding the consideration taken for the purchase of the goods or services.
- Disclosing the personal information of the consumer.
15. IA filled by the complainant to direct the OP to produce original bills & discharge certificate to the complainant is dismissed with No cost, since the bills and other documents submitted to the AB-ArK authority by the OP for the claim, if any disputes the complainant is free to approach the AB-ArK authority i.e. The Executive Director, Suvarna Arogya Suraksha Trust Arogya Soudha, 7th Floor, Magadi Road, Bengaluru – 560023 or The Additional Chief Secretary to Government,/ Principal secretary of Health & Family Welfare Department, 1st Floor, Vikasa Soudha, Bangalore.
16. In this case, the complainant allegation, that the OP charged and collected Rs 118989.00 or more to treat the complainant, without informing the complainant regarding details of cashless service admissible for the complainant under the AB-ArK scheme and other required services provided to the complainant, the OP in its objection filled in Para No 2, denied as false, wherein the documents produced by the complainant Ex R3, Ex R4 & Ex R10, in OP bill dated 22-09-2020 @ 9.49 AM the bill heading IP credit bill details, shown as payment details as receipt No HPR200912175 dated 12-09-2020 (Cash) Rs 20000.00, HPR200916359 dated 16-09-2020 (cash) Rs 66000.00 and HPR200921359 dated 21-09-2020 (cash) Rs 20000.00 collected by the OP from the complainant. The cash receipts produced by the complainant proves that the OP collected Rs 118989.00 from the complainant towards treatment.
17. In the above discussion, in this case the complainant, being APL card holder having enrolled under AB-ArK scheme, the benefit limit shall be 30% of Government package rates, with overall annual limit of INR 1.50 lakh per family per year on a co-payment basis, accordingly the complainant admitted to the OP hospital and taken treatment under AB-ArK scheme is an admitted facts, the dispute is that the OP collected Rs 118989.00, and more from the complainant towards treatment inspite of the complainant admitted under AB-ArK scheme cashless treatment. It’s the bound duty of the OP to inform and update the complainant on available cashless treatment under AB-ArK scheme and required service / treatment to be paid by the complainant, but the OP fails to do so, and collected Rs 118989.00 from the complainant, which leads to ‘Unfair trade practices’ and deficiency of service by the OP. The OP counsel on 10-07-2023 filed memo along with the claim information of the complainant, (AB-ArK scheme) Ref Id AB_Ark_H_219183246782, where in the OP claimed Rs 85000.00 and the AB-ArK authority approved Rs 52000.00. The OP already collected the Rs 118989.00 from the complainant towards treatment; the OP is liable to pay the Rs 52000.00 to the complainant along with interest 8% pa from 09-11-2020. The Complainant approached the OP several times to sought information on considered cashless treatment under AB-ArK scheme and extra charged on service / treatment given to the complainant, but the OP fails to provide the necessary information and clarification and compelled the complainant to approach this commission, hence the OP is liable to pay litigation cost of Rs 10000.00 and compensation of Rs 10000.00 to the complainant, accordingly we proceed to pass the order as;
:O R D E R:
Complaint filed by the complainant is allowed in part.
The OP is ordered to pay, Rs 52,000.00 (Rupees Fifty thousand only) to the complainant along with interest 8% pa from 09-11-2020 to till realization. It is further ordered that OP to pay Rs.10,000.00 (Rs.Ten Thousand only) towards litigation costs and Rs 10,000.00 (Rs.Ten thousand only) towards compensation to the complainant.
The OPs are further directed to comply the above order within 45 days from the date of receipt/knowledge of the order; otherwise, it carries fine of 150/- per day till realization.
Applications pending if any, stands disposed of in terms of the order.
Furnish the copy of order to the complainant and opposite party at free of cost.
