This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that complainant possesses continuous and successive insurance policy on payment of premiums since 1996 and the present policy for the period 2012-2013 was due for renewal on 25-11-2013 and premium cheque of Rs.15,584/- was paid by the complainant to the OP on 20-11-2013 and complainant received renewed policy on 29-11-2013 for the term 26-11-2013 to midnight of 25-11-2014.

          During that period complainant was diagnosed with swelling on the groin on 21-11-2013 and was advised for hernioplasty with prolene mesh.  Complainant sent an e-mail on 20-11-2013 to Assistant Manager of OP1 giving intimation of hospitalization and asked for cashless relief and the complainant was informed by the hospital that he need not pay any deposit for the approved package deal with the OP1 and complainant also need only to pay for the non-medical sundry items, and certain other expenses and complainant was also assured by the OP for cashless transaction of an amount of Rs.24,000/- as per TPA regulations and the rest of the amount had to be paid by the complainant which shall be reimbursed after submission of the claim form along with medical bills.  But despite regular follow up OP did not respond and did not refers the said amount and in the situation complainant’s son paid the entire amount of the entire bill and released his father at 9-30 a.m. in the morning but finally at 12-07 p.m. the entire amount was paid and practically for delay of which payment complainant failed to get cashless benefit and practically for the deficiency and negligent manner of service of the OP and subsequently complainant further prayed for balance amount and after consideration in this case complainant’s main complaint is that OP TPA did not render proper service and he was in delay to pay the same about 6 hours and for which the complainant was compelled to pay the entire hospital costs for not getting benefit of the cashless benefit in time and for compensation.

          On the other hand, the OP by filing written statement has submitted claim was fully settled as per policy condition there was no negligence and deficiency on the part of the OP and there is no material to show that he was harassed and payment of cashless facilities after lapse of six hours does not come within the purview of the deficiency of service.  Moreover, the complainant did not intimate the fact of any deficiency of service by the TPA to the Insurance Company at any material point of time and when the entire claim was satisfied and complainant had enjoyed it, there is no deficiency of service and for which the same shall be dismissed.        

Decision with Reasons

          After hearing the complainant and Ld. Lawyer for the OP and also considering the entire fact it is proved that cashless benefit was given to the complainant but it was received after six hours from the time of discharge of the complainant from the hospital but such a gap cannot be treated as negligent manner of service on the part of the TPA but most interesting factor is that the said medical hospital in which complainant was admitted ought to have waited for six hours for getting the said claim but practically the hospital authorities are well aware of the fact that the complainants insurance is covered by mediclaim policy and there is an agreement between the TPA and the present hospital where complainant was admitted and already OP informed the complainant’s hospital that same shall be released within a short time but hospital authority even after getting such information did not wait for six hours to receive the same and that is the unethical practice on the part of the hospital authority and for which TPA cannot be made accused and in the particular case we are failed to understand for what reason the case was filed.

          In this regard we have gathered that main grievance of the complainant is that if the cashless benefit amount would be received by the hospital authority before his departure in that case the complainant shall not have to pay the entire amount but fact remains some hours is required to prepare the cashless benefits and to send it to the hospital by the TPA.  Hospital authority was senseless, notorious and unmerchantable then invariably it can be said that only for 3 or 4 or 5 or 6 hours delay for cashless facilities thousands of complaint shall be filed against TPA but the present hospital authority should be taught the morality of their medical trade because this Pvt. hospitals are not for here and there for serving his people but they are for earning money and to continue their life-trade having no Seba and they are for money and there is so many examples when a person dies in Pvt. Hospital and his or her family is unable to pay in that case hospital authority keeps the dead body till full payment.  This is the moral sense of Pvt. Nursing home or hospital and how their morality can be changed and that is the question and in this case it is a case of unmerchantable attitude of the hospital authority and practically for lack of patience of the hospital authority this case was filed by the complainant but negligence or deficiency on the part of the OP is not proved.

In the result, the complaint fails.

Hence,

Ordered

That the case be and the same is dismissed on contest without cost.

          Principal/Superintendant of KPC Medical College and Hospital, Jadavpur, is directed to be more moral in respect of any payment by the TPA in respect of treatment of any patient in future because there is a contract or agreement in between the TPA and medical hospital regarding that and in future the KPC shall have to teach morality to the student and staff to serve the patient with devotion and also to teach their administrative staff the morality at first because without morality the whole hospital system shall be a life trade but not a Seba and, in fact, in our country particularly in West Bengal Pvt. Hospitals knows how to collect money but does not know how to render service to the patient for his proper recovery and to give satisfaction to the patient.  So, moral ethics should be learnt by the concerned hospital authority in future otherwise many medical colleges may be established but the proper health service cannot be received by the patient and fact remains many benefits which should be given to the patient cannot be given by the hospital authority.  So, it is our request to the hospital authority to take such class at least once in a month to learn the ethics of medical justice system and services to the patient.