By Sri. MOHANDASAN.K, PRESIDENT
Case of the complainant is as follows:-
1. The mother of the complainant was got admitted in the first opposite party hospital on 16/07/2022 at about 10 pm. Prior to the admission the complainant had enquired about the medisep insurance coverage and the first opposite party had assured the medisep insurance benefit for the treatment before the first opposite party. The mother of the complainant was taken to the MICU for the treatment since her condition was serious. The opposite party informed the complainant and the family that the condition of the patient is not improving subsequently and on 21/07/2022 the mother died. The complainant did not allege medical negligence against first opposite party and believe that they provided possible medical attendance.
2. The complainant remitted 1, 84,292/- rupees towards the treatment expense and the first opposite party had assured that they will refund the amount on receipt of medisep benefit towards the treatment. But the complainant submitted he did not receive any amount form the first opposite party towards the treatment expense till him filing this complaint. The complainant submitted that he had issued lawyer notice dated 22/09/2022 seeking refund of the treatment amount along with compensation of 1,00,000/- rupees within in 15 days after receipt of notice. The first opposite party sent a reply dated 17/10/2022 denying the entire averments and allegations.
3. The complainant submitted that the treatment of the patient was commenced on assurance of medisep insurance coverage. It is submitted the complainant had noted paper news published in malayala manorama daily that the treatment before the first opposite party is covered under medisep scheme. The mother of the complainant was covered under medisep scheme since the complainant being a government employee. Though the complainant demanded medisep insurance benefit the first opposite party denied the same and insisted to pay the treatment expense before releasing the dead body of the mother of complainant. The complainant managed treatment expense from friends and relatives and thereby remitted the treatment expense to the first opposite party. If the opposite party had informed the fact that there is no insurance coverage for the treatment the patient would not have admitted in that hospital for the treatment. Hence the complainant alleged deficiency in service and unfair trade practice on the part of the first opposite party and prayed for the treatment expense along with compensation of Rs.1,00,000/- and cost of Rs. 25,000/- and interest thereon
4. On admission of the complaint notice was issued to the opposite parties and the opposite parties 1and 2 entered appearance and filed version.
5. The first opposite party denied the entire averments and allegations in the complaint and submitted that the cause title is in correct one. It is submitted the first opposite party is Malabar institute of medical science limited, Kottakkal and the submission is that the complaint is misconceived one. It is prayed dismissal of complaint for non- joinder of necessary parties. It is further contended that the legal heirs of deceased Aysha, doctors and insurance officers are necessary parties in the complaint.
6. The opposite party admitted the admission of the patient before the opposite party and the ailment and treatment undergone before the first opposite party. It is submitted that the patient initially availed treatment from MB hospital Malappuram and for expert management she got admitted in the first opposite party hospital. At the time of admission the counselling team of the first opposite party explained the possible treatment cost, procedures, doctors charge, room charges, emergency charges etc. in details to the bystanders. The complainant accepted the same and signed in consent form. Thereafter the patient was admitted for further management. She was intubated and mechanically ventilated and was shifted to MICU for further management. The bystanders or any one not informed existence of insurance policy or such other coverage. The averment that the hospital authorities promised to get medisep insurance for treatment is incorrect. There was no promise or assurance from the hospital for providing the insurance coverage to the patient. The opposite party is not arranging insurance coverage for any of the patient by its own. The patient with insurance coverage can claim the benefit from the insurance company and the opposite party will provide necessary details to the insured or its insurance official on demand. In this complaint no insurance officials or any one contacted the opposite party for any details as alleged.
7. The opposite party provided the possible medical treatment to the patient and the conditions were explained in detail to the relatives, bystanders and other person who enquired the details by the hospital staff. They were keep on saying the hospital authorities can do all possible treatment and they are willing to pay the hospital bill as per the norms of the hospital.
8. The conditions of the Patient was not improving despite all efforts and informed that the drugs are not acting on her body. The patient need further hospital stay and the management and its expenses were explained to the by standers and relatives. Then the relatives informed that they are shifting the patient to an alternative centre and thus on request discharged and referred the patient to MBH hospital Malappuram. The opposite party submitted that they provided service of expert doctors and provided treatment which is universally accepted standard medical protocol, bestowing all care, caution and she was given appropriate treatment and management. The bystanders and family members were fully apprised the treatment undergone before first opposite party.
9. The first opposite party submitted that medisep insurance coverage claim of the hospital will not cover the internal medicine treatment. The opposite party replied to the lawyer notice of the complainant in details. The opposite party denied the averment that the patient was admitted in the hospital due to the advertisement in various new papers claiming the medisep insurance is available in Kottakkal Aster MIMS is baseless. It is specifically submitted that the external medicine treatment is not included in the meidsep insurance claim as per the signed agreement with the insurance company. There are treatments for cardiology, ENT, Neurosurgery, urology, catastrophic illness which are available under medsiep and the same are exhibited in the hospital. The opposite party explained various treatment provided in the first opposite party. It is submitted that the treatment bill was Rs. 2,09292.51/- and there was a total discount of Rs. 25,000/- in favour of the complainant. The bill was issued to by stander as per request. But the averments that there was promise to avail medisep insurance for the patient, that paid an amount of Rs 1, 84,292/- at the time of admission, that there was promise to repay the treatment expenses after verifying the medisep card that there will not be any charges for the treatment, that the death occurred in the hospital that the amount was not returned as per promise etc. are incorrect and so the opposite party denied. It is submitted there is no basis for the claim for refund of Rs.1, 84292/-and compensation of Rs. 1, 00,000/- to the complainant hence the complainant is not entitled any relief as prayed in the complaint.
10. The second opposite party filed version denying the allegations of the complainant. The second opposite party submitted that the complainant did not produce ID under medisp insurance scheme, complainant has not disclosed the number of ID under the medisep insurance scheme and so the second opposite party was not able to identify the complainant or his beneficiary.
11. The second opposite party submitted that they never received any intimation or information either from the complainant or from the first opposite party regarding the admission of Ayisha in the hospital and her eligibility for medisep insurance and so the second opposite party is unaware about the hospitalisation of Aysha at the hospital run by first opposite party.
12. The opposite party submitted that the legal heirs are not parties in the complaint and so the complaint is bad for non-joinder of necessary parties. The opposite parties submitted that the complainant alone is not the legal heir of the deceased Ayisha.
13 The opposite party submitted the complainant did not produce medical records along with the complainant to comment upon the lines of Ayisha and treatment conducted at the hospital. Without presuming the records the opposite party is not able to say whether the treatment is covered under the medisep insurance scheme.
14. The opposite party submitted that a lawyer notice seen issued against fist opposite party on 22/09/2022 under the instruction of Ayisha who as per the document seen died on 21/07/2022. The first opposite party sent a reply for the notice stating how the deceased can issue notice and give instruction to issue notice. Hence the lawyer notice has no legal sanctity and the complainant or Ayisha has never issued a lawyer notice against the opposite party. In the above facts and circumstances the opposite party submitted that the complaint is not maintainable and not entitled any relief as prayed. There is no deficiency in service on the part of the opposite party and so the provisions of Consumer Protection Act is not applicable against the second opposite party.
15. The third opposite party did not file version but sent a letter to this commission dated 08/05/2023 stating that they had issued direction to the first and opposite parties to enquire in to the matter and to submit the report before the commission.
16. The complainant and the opposite parties 1 and 2 filed affidavit and documents. The documents of the complainant marked as Ext.A1 to A6. Ext. A1 is copy of lawyer notice dated 22/09/2022 issued by Adv. Abdul Shukoor to the manager, Aster MIMS Kottakkal, Malapapurm. Ext A2 is copy of replay notice issued by Aster MIMS hospital Calicut to Mr Abdul shukkoor Advocate Manjeri dated 17/10/2022. Ext. A3 is copy of medical bills for Rs. 1, 84,292 dated 21/07/2022. Ext. A4 is copy of lawyer notice issued by Abdul Shukoor advocate to the Oriental Insurance Company Limited New Delhi and Metro palace Xavier Arakkal road, Kochi. Ext. A5 is postal acknowledgment. Ext.A6 is medisep card in the name of Ayisha CH. The opposite party did not produce documents.
17. Heard complainant and opposite parties 1 and 2, perused affidavit and documents. The following points arise for consideration:-
1) Whether there is deficiency in service on the part of opposite parties?
2) Relief and cost?
18. Points 1 and 2
The case of the complainant is that his mother got admitted for the treatment before the first opposite party on assurance that the treatment expense is covered under medisep insurance scheme. The mother of the complainant undergone treatment before first opposite party but she could not survive. Thereafter the complainant claimed refund of medical expenses paid to the first opposite party but the first opposite party or other oppose parties did not refund the treatment expense, hence alleged deficiency in service and unfair trade practice on the part of opposite parties .
19. The opposite parties 1 and 2 contended that the complaint is defective for non-joinder of necessary parties and the complainant alone is not the sole legal heir of the deceased Ayisha. It is further contended that the lawyer notice produced as Ext. A1 issued under the instruction of smt. Ayisha who was no more at the time of issuing the notice. The first opposite party further submitted that the treatment undergone by the patient was not covered by medisep insurance coverage in the hospital and so the complainant is liable to pay the treatment expenses incurred therein. It is specifically submitted by the first opposite party that the fact was informed to the complainant and the family members and thereafter the patient was undergone treatment therein.
20. The second opposite party submitted that they were totally unaware of treatment of the patient Ayisha and the medical expenses and the medisep details as contended in the complaint.
21. It appears the patient was undergone treatment before the first opposite party wherein medisep insurance coverage is available for certain treatments but not include the treatment of internal medicine provided to the patient Ayisha. So the complainant is not entitled medisep insurance coverage and liable to pay the treatment expense. So there is no meidsep insurance protection for the treatment of patient Ayisha and no chance to contact the second opposite party for the treatment expenses through medisep insurance scheme. Hence the submission of the second opposite party is also appears valid one. Moreover the issuance of notice on behalf of a deceased person cannot be treated as a valid notice.
22. Considering the entire facts and the documents we do not find merit in the complaint and there is no reason to direct the opposite parties to provide the treatment expense as claim in the complaint. Hence the complaint stands dismissed.
Dated this 30th day of October, 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 A6
Ext.A1: Copy of layer notice dated 22/09/2022 issued by Adv. Abdul Shukoor to the
manager Aster MIMS Kottakkal , Malapapurm .
Ext.A2: Copy of replay notice issued by Aster MIMS hospital Calicut to Mr Abdul
shukkoor Advocate Manjeri dated 17/10/2022.
Ext A3: Copy of medical bills for Rs. 1, 84,292 dated 21/07/2022.
Ext A4: Copy of lawyer notice issued by Abdul Shukoor advocate to the Oriental
Insurance Company Limited New Delhi and Metro palace Xavier Arakkal road,
Kochi.
Ext A5: Postal acknowledgment.
Ext.A6: Medisep card in the name of Ayisha CH. The opposite party did not produce
documents.
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
