Complaint filed on:10.12.2022.
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.148/2022
Sri.Venugopalan .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 1,50,167/- @ 24% p.a. from the date of payment to till filing the present complaint and also prays to direct the OP to pay compensation of Rs.5,00,000/- for the fear and worry because of not claiming any insurance.
2. In this case opposite party was / is Shridevi institute of medical Sciences and Research Hospital, NH-4, Sira road, Tumkur, Karnataka .herein after called as OP / OP hospital.
- . It is the case of the complaint, that, the complainant being diagnosed as COVID – 19 fever, during September 2020, admitted to the Siddaganga Hospital Tumkur and taken emergency treatment and care, due to non availability of the beds the complainant discharged, later the complainant admitted to the OP hospital from 23.09.2020 to 10.10.2020 and taken the treatment under Ab-ark scheme. The OP failed to provide original discharge summary and the original final bill at the time of discharge and therefore, the complainant, unable to claim any insurance. The complainant further submitted that due to old age factor, panic situation, the family members of the complainant had no option except availing service in the OP hospital. It is further submitted that due to the hospital expenditure crossed the complainant’s family financial capacity, they obtained Ab-ark scheme and the said scheme covered only a part of complainant’s total bill amount and large number of payments were made by the complainant’s family out of their own pocket. The bill and discharge summary given by the OP did not have any proper sign and seal of the hospital. In spite of request made by the complainant and his family members to give original discharge summary and bills, the hospital authority fails to furnish the same. When the hospital has charged amounts, it is the duty of the hospital to provide bills and original documents; it shows the deficiency of service on the part of OP. Hence, the complainant filed this complaint with a prayer to direct the OP to pay the amount which has been paid by the complainant to the Hospital as he has been unable to claim any insurance on account of the hospital not providing the original documents along with interest on the amount of Rs.1,50,167/- @ 24% p.a. from the date of payment to till filing the present complaint and also prays to direct the OP to pay compensation of Rs.5,00,000/- for the fear and worry because of not claiming any insurance.
- After the complaint registered, notice was served to the OP. The OP counsel appeared and contended that the complainant initially diagnosed as COVID – 19 fever, during September 2020, admitted & taken emergency treatment and care, in the Siddaganga Hospital Tumkur and due to non availability of the beds the complainant discharged, later the complainant admitted to the OP hospital on 23.09.2020 due to the history of fever and cough, diagnosed as COVID -19 positive pneumonia, he was admitted under Ayushman Bharath Arogya Karnataka Scheme for COVID 19 treatment, the complainant has not paid any amount for the said duration and the complainant was treated for COVID 19 under Ayushman Bharath Arogya Karnataka Scheme and discharged on 10.10.2020 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. They have sent the original documents to Ab-ark as per the scheme. Hence, there is no deficiency of service on their part. The complaint filed by the complainant is otherwise 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 10-01-2023, 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.
6. The complainant has filed his affidavit evidence. Dr.Raman Hulinayakar, Doctor and Director has filed his affidavit evidence on behalf of OP. The GPA holder of the complainant marked the documents at Ex.C1 to C20. The OP has marked the documents produced by them at Ex.R1 & R2.
- . We have heard the arguments of counsel for the 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 in the affirmative for 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 by producing documents as Ex.C1/Siddhaganga Hospital Emergency treatment bills, Ex.C2/Reference letter given to the OP hospital, Ex.C3/online bank statement of Ms.Anuthara, Ex.C5/Sacred Heart Bank pass book of Mrs Sudhadevi K and Anilkumar .K, Ex.C6/Receipts of bill No.OPB201010046 dated:10.10.2020, Ex.C7/receipts of payments dated:23.09.2020, 25.09.2020 and 10.10.2020, Ex.C8/ABARK prescription along with receipts dated:30.09.2020 and 06.10.2020, Ex.C9/receipts dated 27/09/2020, 28/09/2020, 04/10/2020 and 10.10.2020 which may be compared with the receipts issued to complainant by the OP hospital, Ex.C10/ABARK prescription along with receipts dated:23.09.2020 and 28.09.2020, Ex.C11/receipts dated:01.10.2020, 04.10.2020 and 06.10.2020, Ex.C12/prescriptions dated:28.09.2020 and 02.10.2020, Ex.C13/discharge summary provided by the OP hospital, Ex.C14/discharge summary of the Hospital at Bangalore, Ex.C15/Whatsapp Chat Printout, Ex.C16/Request letter to OP/Hospital dated:01.09.2021, printout of the website of Z info solution Private Limited, Ex.C18/Printout of the details procured from the GST website, Ex.C19/ATM details taken from the website of Canara Bank and Ex.C20/affidavit under S-65(B) of Evidence Act.
11. The OP counsel argued that, the complainant admitted to the OP hospital on 23.09.2020 due to confirmed COVID pneumonia, 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 complainant admitted to the OP hospital 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 two documents.
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 150167.00 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 7, denied as false, wherein the documents produced by the complainant (page 34) in OP bill No OPB201010047,dated 10-10-2020 @ 01.54 pm, the bill heading OP cash bill, Rs 112399.00, In (page 32) in OP bill No HPR200923012,dated 23-09-2020 @ 02.08 AM, the bill heading Receipt, Rs 10000.00, In (page 33) in OP bill No HPR200925076,dated 25-09-2020 @ 10.26 AM, the bill heading Receipt, Rs 15000.00, collected by the OP from the complainant. The cash receipts produced by the complainant proves that the OP collected Rs 150167.00 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 150167.00, 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 150167.00 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_21918333942, where in the OP claimed Rs 1,62,500.00 and the AB-ArK authority approved Rs.1,19,100.00. The OP already collected the Rs.1,50,167.00 from the complainant towards treatment; the OP is liable to pay the Rs 1,19,100.00 to the complainant along with interest 8% pa from 08-04-2021. 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.1,19,100.00 (Rupees One Lakh nineteen thousand one hundred only) to the complainant along with interest @ 8% pa from 08-04-2021 to till realization. It is further ordered that OP to pay Rs.10,000.00 (Rs.Ten Thousand only) towards litigation costs and Rs10,000.00 (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.
