BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

   17^th DAY OF DECEMBER 2019

O R D E R

SMT.PRATHIBHA. R.K., PRESIDENT

This complaint is filed by the complainant against the Opposite Parties (herein after called as OPs) under section 12 of the Consumer Protection Act, 1986.  The complainant prays to direct the OPs to pay a sum of Rs.30,000/- with 12% interest from 15.05.2015 till payment, to pay Rs.50,000/- towards compensation, to pay Rs.10,000/- as expenses and such other reliefs.

2.      The brief facts of complaint is as under:

Complainant submitted that the Government of India had launched a Health Insurance scheme called Rashtriya Swasthya Bima Yojana (herein after called as RSBY) for Below Poverty Line (BPL) families.  The objective of RSBY is to provide protection to BPL cardholders from financial liabilities arising out of health issues that involves hospitalization.  Every beneficiary under RSBY is entitled to hospitalization upto Rs.30,000/- for most of the diseases that required hospitalization.  Government has also fixed the package rates for the hospital for a large number of interventions.  Pre-existing conditions are also covered from day one and there is no age limit.  The said policy extends to five members of the family.  The beneficiaries need to pay Rs.30/- as registration fees.

The complainant further submitted husband of the complainant Gurappa Nanda, subscribed to the scheme for the year 2015-16.  He has paid Rs.30/- as prescribed fee and forthwith a Health Card has been issued.  The complainant further submitted that the complainant has admitted to OP-2 Hospital and a major operation was done on 15.05.2015, for which she has paid Rs.1,50,000/-.  The complainant further submitted that on the day of operation, the complainant showed her card for concessional treatment to the OP-2.  OP-2 did not hear the complainant request and operation was conducted and she was compelled to pay full amount.  Accordingly complainant paid the payment.  Thereafter the legal notice was sent to OP-1 along with bill and discharge summary & requested to reimburse the payment made to the hospital by the complainant.  OP-1 had not replied to the said letter.  Hence the complainant approached this Forum.  

3. In response to the notice issued, OP-1 appeared through their advocate and filed their version in brief as under:

OP-1 submitted that OP-2 has been empanelled under RSBY Karnataka policy to provide cashless facility to RSBY beneficiary.  OP-2 has not provided cashless benefits to RSBY beneficiary which is clear cut violation of scheme and guidelines formulated by the Central Government while implementing the said RSBY scheme.  Therefore an explanation was called by the OP-1 with the OP-2 in this regard.  OP-2 sent a reply to OP-1 through letter dated 22.03.2016 contending that they have not started treatment/services to the patients under RSBY scheme as the Memorandum of Understanding between the hospital for RSBY has not been approved and signed by the OP-1 and they were still waiting for the approval and signed MOU.  Therefore the absence of duly executed MOU, OP-2 has not provided cashless facility to RSBY beneficiaries.  Hence they denied violation of RSBY guidelines.  In the said letter OP-2 stated that the complainant was treated as self-paying patient and paid the full bill amount at the time of her discharge and all the medical bills along with discharge summary were handed over to the complainant. 

OP-1 further submits that the total amount mentioned in the bill which was submitted by the complainant along with his complaint is mismatch (i.e., Rs.5,650.30 instead of Rs.45,293.00), hence the present complaint filed with malafide intention and it is not legally maintainable.  Therefore the complainant cannot allege deficiency of service.

OP-1 further submitted that as per the RSBY scheme the maximum package charges are fixed by the Government as per ailment/procedure for benefits covered by the Insurance Scheme.  As per the bill produced by the complainant the complainant obtained the treatment in Semi Private Ward.  Hence the present complaint is liable to be dismissed on this ground.  Moreover the OP-1 has not received any information along with documents with regard to the treatment obtained by the complainant as per RSBY scheme.

OP-1 further submitted that it was responsibility of the OP-2 hospital to inform the beneficiary about RSBY card acceptance in hospital.  If the said card was not accepted by the hospital, beneficiary should have raised the grievance on immediate basis which has not been done.  Also, no hospital can bound the patient for treatment especially surgery without consent.  In this case the patient willingly choose to undergo the operation at the said hospital at her own risk knowingly that RSBY card is not available in the hospital and no grievance was been raised for more than 9 months with the OP.

Further OP-1 submits that OP-1 received the copy of bill amounting to Rs.42,593/- only and no other documents like discharge summary etc., was provided to the OP-1.  Even otherwise the present case do not call for any claim reimbursement as the RSBY is pure cashless insurance policy.  Rest of the allegations made by the complainant is denied in toto.  Hence OP-1 prayed for dismissal of the complaint with cost.

4. In response to the notice issued, OP-2 appeared through their advocate and filed their version in brief as under:

OP-2 submits that the complainant approached OP-2 hospital for treatment on 14.05.2015 and she was admitted and treated as a self-paying patient.  Complainant did not intimate the hospital at the time of admission that she was a beneficiary under the RSBY scheme, neither did she produce any documents in this regard.  Further OP-1 was not a network hospital during the period when the complainant took treatment at the hospital.  Hence the hospital was under no obligation to provide concessional treatment to the complainant under RSBY scheme.  Hence the complainant paid for the treatment and got discharged.  OP-2 further submits that an agreement was entered into between OP-2 hospital and Medi Assist India TPA Pvt. Ltd., for the period 2013-14 to provide treatment for RSBY members under the said scheme.  The agreement expired in the year 2014 and the agreement was not renewed by the parties subsequently.  Further the TPA changed in the year 2014 and was replaced by the Paramount Health Services Pvt. Ltd., as TPA.  With the earlier TPA the OP-2 entered into an agreement for implementation of RSBY scheme was no longer the TPA from the year 2014.  The agreement entered into the said TPA would become redundant.  Hence the fresh agreement was to be entered into in view of the change of Third Party Administrator.  In fact though the hospital sent across the duly signed agreement/MOU, the approval along with signed copy of MOU and activation of software to treat RSBY beneficiaries was never forthwith from the Third Party Administrator, Paramount Health Services Pvt. Ltd.  No agreement was received from the OP-1 or from TPA regarding to extending the RSBY scheme.  Hence OP-1 was under no obligation to treat the patient under the said scheme.  Without subsisting agreement and activation of software, the OP was in no position to extend its services under RSBY scheme.  Thus no liability can be fastened on the hospital.  The complainant took the treatment without verifying as to whether OP-1 hospital is a hospital providing for service under RSBY scheme and now cannot make a claim that the hospital is liable to reimburse Rs.30,000/- as per the scheme.  Without there being any agreement of the hospital with OP-1 or the TPA, there would be no reimbursement given to the hospital by the OP-1 for the treatment given to the patient.  Hence the question of refund of the treatment amount to the extent of Rs.30,000/- does not arise.  Hence OP-2 prays for dismissal of the complaint with cost.  

5. In the course of enquiry into the complaint, the complainant and the OP-2 have filed their affidavit reproducing what they have stated in their respective complaint and objections.  Complainant has submitted written arguments.  Complainant and OPs have produced certain documents.  We have heard the arguments of complainant and OPs and we have gone through the oral and documentary evidence of both parties scrupulously and posted the case for order.

6. Based on the above materials, the following points arise for our consideration;  

1. Whether the Complainant has proved that there is deficiency in service on the part of the OPs, if so, whether he is entitled for the relief sought for?

2.  What order?

7. Our findings on the above points are as under:

Point No.1:  In Negative

Point No.2:  As per the order below

REASONS

8. Point No.1:  On perusal of the pleadings, evidence and documents produced by both the parties, it is an admitted fact that the complainant was admitted to the OP-2 hospital as an inpatient on 14.05.2014 and undergone the surgery on 15.05.2015 and discharged on 18.05.2015.  The complainant alleged that at the time of surgery she showed the card for concessional treatment.  The OP-2 did not hear the request of complainant and operation was done.  The complainant was compelled to pay the full amount and discharged from the hospital.  Thereafter the complainant issued a legal notice to OP-1 along with bill claiming of the reimbursement expenses incurred by the complainant.  Till today the OP-1 has not settled the expenses.

9. On the other hand OP-1 disputed that OP-1 received the copy of the bill amount of Rs.45,293/- only and no other documents like discharge summary was provided to OP-1.  Further as per the bill it is seen that the complainant admitted in the Semi Private Room category.  As per the RSBY scheme beneficiary who take the treatment under general ward.  Hence there is a clear cut violation of the RSBY scheme.

10. As per OP-2 contention the complainant has not intimated about beneficiary under the RSBY scheme to OP-2 at the time of admission to the hospital as an inpatient.  The complainant admitted and treat as a self-paying patient she has undergone surgery and paid the amount and got discharged.

11. Admittedly the complainant husband paid Rs.30/- as a registration fees to avail the benefits of RSBY scheme for himself and his family members in the year 2015-16.  The complainant was admitted to the hospital and underwent a surgery on 15.05.2015 and discharged on 18.05.2015 by paying the bill amount.  The complainant in her complaint and also in her affidavit evidence stated that at the time of surgery she has informed the hospital to treat her under RSBY scheme.

12. Complainant has not admitted to the hospital under RSBY scheme.  It is only at the time surgery she claims under RSBY scheme.  If at all the complainant at the time of admission had claimed under RSBY scheme, OP-2 was at liberty to reject her claim.  She claims to her benefit on RSBY scheme at the time of surgery.  OP-2 has not considered her claim as a beneficiary under RSBY scheme.  OP-2 has considered as a self-paying patient.  Further the complainant has approached this Forum after surgery that too after paying the medical bill.  The complainant has to ascertain whether she is beneficiary under the scheme at the time of admission itself.  Now she cannot turn back and say that the scheme is applicable to her and OP-2 has not treated her under RSBY scheme.  Further the agreement between OP-2 and TPA had expired on 2014 and thereafter no agreement was entered.  Hence the OP-2 could not have given the complainant the benefit of RSBY scheme.  Hence on the above facts and circumstances of the case the complainant has failed to prove deficiency of service on the part of OPs as alleged in the complaint.  Therefore, the complaint is liable to be dismissed.  Accordingly, we answer the point No.1 in the negative.

13. Point No.2: In the result, for the foregoing reasons, we proceed to pass the following order:          

  O R D E R

The complaint filed by the complainant is dismissed.  No order as to costs.

 Supply free copy of this order to both the parties.

(Dictated to the Stenographer, transcribed and typed by him, corrected and then pronounced by us in the Open Forum on this, the 17^th day of December 2019)

(ROOPA N.R)                                             (PRATHIBHA R.K)

   MEMBER                                                     PRESIDENT

Witnesses examined on behalf of the complainant by way of affidavit:

Smt.Neelavva @ Neelakka

Copies of documents produced on behalf of complainant:

Documents produced on behalf of Opposite Party-1

Witnesses examined on behalf of the OP-2 by way of affidavit:

Sri.Revanasiddappa Jigjinni, who being the In-charge of Legal Cell of OP-2.

Documents produced on behalf of Opposite Party-2

(ROOPA N.R)                                             (PRATHIBHA R.K)

   MEMBER                                                     PRESIDENT

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