Delhi

East Delhi

CC/641/2014

JAGDISH PRASAD - Complainant(s)

Versus

CLAIM HEALTH SERVICES - Opp.Party(s)

19 Oct 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. No.641/2014

 

	Shri Jagdish Prasad Gupta S/o Late Shri Balbir Singh Gupta R/o House No.401, Parivar Apartment, Plot No.30, I.P. Extension, Patparganj, Delhi-110091	….Complainant
Versus
	The Addl. Director (Claim) Health Services Room No.10, CGHS Dispensary Laxmi Nagar, Delhi-110092.	……OP

 

 

Date of Institution: 17.07.2014

Judgment Reserved on: 07.10.2022

Judgment Passed on: 19.10.2022

                  

CORUM:

Sh. S.S. Malhotra (President)

Ms. Ritu Garodia (Member)

Sh. Ravi Kumar (Member)

 

Order By: Ms. Ritu Garodia (Member)

 

JUDGEMENT

1. The Complaint pertains to deficiency in service on part of OP in repudiating a part of the mediclaim of the Complainant. 
2. Brief facts as stated in the complaint are that the wife of the Complainant Smt. Vimla Gupta was admitted in Max Super Speciality Hospital, Patparganj, Delhi on 22.09.2012.  She expired on 26.10.2012.  The total bill raised by the Hospital was Rs.19,80,078/-. on which certain discount was given by the hospital and the remaining amount of Rs.11,55,000/- was due. The Complainant tendered a claim with OP, giving a list of expenditure details. A copy was sent to Health Minister, Nirman Bhawan, New Delhi, and Secretary and Director General, Ministry of Health and Dr. Naresh Panchal, Room No. 8, CGHS Dispensary, Laxmi Nagar.
3. The Complainant had a mediclaim policy and Rs.5,00,000/- was paid directly to the Hospital by the insurance. The remaining amount was Rs.6,55,000/-. It is imputed that Dr. Panchal passed the bill for an amount of Rs.2,54,795/- initially, vide letter dated 19.12.2012, and paid only Rs.1,55,000/- to the complainant that too without  any explanations. On a hue and cry raised by the complainant, another amount of Rs.3,56,279/- was paid, and total amount of Rs.5,11,279 /- was released but, the balance amount of Rs.1,43,721/- not released.   
4. It is stated that the mediclaim has to be paid within three months from date of submission i.e. 06.12.2012. Further, the patient was admitted in an emergency for multiple organ failure and should have been reimbursed in full. Inspite of fixed guidelines, the claim has been assessed in different way. The Complainant sent many representations and even a legal notice to OP. The complainant was suffering as he had to return the amount to the money lenders who were charging interest @ 18% p.a. The Complainant prays that a balance amount of Rs.1,43,721/- should be paid with interest @ 24% p.a., compensation to the tune of Rs.1,00,000/- and the costs incurred by the Complainant. 
5. OP in its reply has submitted that the Complainant is a pensioner beneficiary of Laxmi Nagar, Wellness Centre having CGHS Card No.994184, which entitles him for private ward and is valid for whole life.  His wife late Smt. Vimla Gupta was a dependent CGHS beneficiary having a card bearing No.994185. 
6. OP further states that Smt. Vimla Gupta was admitted in emergency to Max Super Speciality Hospital, Patparganj, Delhi on 22.09.2012 with complaint of pain in abdomen and nausea for 2-3 days.  The said hospital was not empanelled in September, 2012. Smt. Vimla Gupta was a follow up case of acute pancreatitis. As per the emergency certificate, the patient was diagnosed as a case of sub-acute intestinal obstruction (SAIO) with gangrene of bowel with septic shock and renal failure with acute respiratory distress syndrome (ARDS) and she was advised admission.  She was taken for surgery twice. First surgery (Exploratory Laparotomy with Resection and Anastomosis) was done on 13.10.2014. Gangrene of ileum proximal to anastomosis was found and so the second surgery (re-exploration with resection of gangrenous segment with ileostomy) was done on 22.1.2012. Post operation she was in critical state and required ventilator support. On 26.10.2012, she had a sudden cardiac arrest and despite resuscitation measures, she could not be revived. The cause of death in the death summary is stated as septicaemia with septic shock with multiple organ failure. 
7. It is stated that the total bill of the Hospital was Rs.19,80,078/- which was reduced to Rs.11,55,000/- by the Hospital itself out of this amount, Rs.5,00,000/- was paid by Insurance Company, i.e. Dedicated Health Care Services Pvt. Ltd.  A medical reimbursement claim was lodged on 10.12.2012 by the Complainant to OP for a sum of Rs.6,55,000/-.  Initially, an amount of Rs.1,55,000/- was paid.  Later, on re-examination of claim, it was found that new OM NO. S-11011/4/2003-CGHS (P) dated 10.02.2009 regarding reimbursement from two sources had not been followed to calculate the admissible amount.  After re-calculation, the Complainant was paid an additional amount of Rs.3,56,279/-.  Thus, a total amount of Rs.5,11,279/- was paid to the Complainant.
8. OP received a legal notice on 05.06.2014 for reimbursement of balance amount of Rs.1,43,721/-. The case was placed before the Technical Standing Committee (TSC) for full reimbursement on 27.06.2014.  The committee required few more documents.  The Complainant was informed of the same by speed post on 01.07.2014. As the post was received back due to the change in address, the complainant was informed telephonically on 08.08.2014. The Complainant submitted some more documents. 
9. The Review Technical Standing Committee met on 04.09.2014 and the experts of the committee opined that the documents requested during the first meeting had not been obtained and a clarification was to be sought regarding the emergency certificate obtained from Max Super Speciality Hospital, Patparganj, Delhi.  The Complainant was informed vide letter dated 08.09.2014.  It is stated that OP has not received any more documents. It is accordingly prayed that the complaint has no cause of action and complaint be dismissed.
10. The Complainant in his Rejoinder to the reply filed by OP has denied the objections filed by OP and re-affirmed the contents of the complainant. He submits that on receiving a letter dated 08.09.2014 issued by CGHS authority requiring the documents for the claim, he immediately sent a reply vide e-mail dated 16.09.2014. The said email states that the Complainant met Dr. Bachchan Singh and Dr. V.K. Jain at Max Super Speciality Hospital, Patparganj, Delhi for the clarification.  The Doctors stated that all the documents were available with the medical superintendent on his/her e-mail ID. 
11. It is reaffirmed that the patient was admitted in emergency and day to day report regarding Tests etc. has already been submitted to the CGHS department by the Complainant, and summary of the treatment procedure at the time of admission and operation of surgery have already been given to OP. 
12. Complainant has filed his evidence by way of affidavit and following documents are exhibited, and we have perused the same.

1. Bill and Correspondence.
2. Legal Notice dated 03.06.2014.
3. Acknowledgment receipt of the legal notice dated 10.06.2014.
4. Calculation sheet.
5. Correspondence between parties.

13. Right of OP to file evidence by way of affidavit was closed vide Order dated 22.09.2015.  Order dated 12.07.2018 shows that the complainant has given the required documents to OP.
14. The Commission has considered the pleadings and material placed on record.  It is submitted that the complainant and his late wife were CGHS beneficiaries having card No.994184 and 994185 respectively. It is admitted that the wife of the Complainant, late Smt. Vimla Gupta, was admitted in emergency to Max Super Speciality Hospital, Patparganj, Delhi on 22.09.2012. Due to pain in abdomen and nausea. She was diagnosed with sub-acute intestinal obstruction (SAIO). She was taken up for surgery twice.  After the first surgery on 13.10.2014, gangrene (Exploratory Laparotomy with Resection and Anastomosis) was found and so the second surgery was done on 22.01.2012.  She did not recover from the said surgery and was put on ventilator support.  She died due to cardiac arrest on 26.10.2012. The cause of death was septicaemia with septic shock with multiple organ failure in the death summary.
15. It is admitted by both the parties that the total medical expenses and the amount paid are as follows:

S. No.
	Total medical expenditure bills were raised by the hospital.
	Hospital has considered / deducted the amount.
	Rest of the amount which was to be paid.
	Amount directly paid by the Insurance to Hospital.
	CGHS has reimbursed an amount to the complainant.
	Now the rest claimed amount, for which the claim is pending.

16. OP in its reply has taken a preliminary objection that complainant is not a consumer.
17. National Commission in Jagdish Singh Chauhan V/s CGHS II (2013) CPJ 725 (NC) has observed that any retired employee joining CGHS, a welfare scheme, fall within the purview of consumer and on this ground matter was remanded for adjudication on merits. This judgment was delivered by six-member bench of the Commission, (NCDRC). Thus, it becomes clear that petitioner being a retired Government employee, who has contributed towards GCHS Scheme, falls within purview of consumer under the Consumer Protection Act.
18. It is stated in OPs reply that an amount of Rs.1,55,000/- was earlier paid.  On re-examination, it was found that there was a calculation error and an additional amount of Rs. 3,56,277/- was paid and a sum of Rs.1,43,723/- was not paid.  Thereafter, OP received a legal notice dated 05.06.2014.
19. OP has filed documents giving procedure followed in cases of request for full medical reimbursement. The relevant portion is reproduced as under:

“(2) All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be referred to a Technical Standing Committee', to be chaired by the DGHS/Addl. DGHS and consist of Director (CGHS) and subject matter specialists. If the Technical Standing Committee recommends the relaxation of rules for permitting full reimbursement of expenditure incurred by the beneficiary, the full reimbursement may be allowed by the Secretary (Health & Family Welfare) in consultation with IFD. A check list for consideration of requests for reimbursements in excess of approved rates may include:

1. The treatment was obtained in a private non-empanelled hospi tal under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalised for a prolonged period;
2. The treatment was obtained in a private non-empanelled hospital under emergency and was admitted for prolonged period for treatment of Head Injury, Coma, Septicemia, Multi organ failure, etc.;
3. The treatment was obtained in a private non-empanelled hospital under emergency for treatment of advanced malignancy:
4. The treatment was taken under emergency in higher type of accommodation as rooms as per his / her entitlement are not available during that period;
5. The treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections;

(f) The treatment was obtained in a private non-empanelled hospital under emergency when there is a strike in Government hospitals;

(g) The treatment was obtained in a private non-empanelled. 

20. OP received a legal notice dated 05.06.2014. Thereafter it constituted a Technical Standing Committee for full reimbursement.  The minutes of the meeting for Standing Technical Committee (STC) held on 27.06.2014 are reproduced as under:

After careful scrutiny among the experts, the STC came to the conclusion that :-

For proper justification of the case following documents are required

1. Detailed investigation reports at the time of admission & day wise case-sheet & ICU reports

2. Detailed summary of the course of the illness during the admission

3. Operative findings of the first operation

The meeting end with a vote of thanks to the chair. 

21. OP has also stated that Complainant has filed some documents.  Thereafter, a Standing Technical Committee (STC) meeting was held on 04.09.2014 for review of the claim.  It was held that the documents requested during the first committee meeting has not been submitted and a clarification was to be sought with regard to emergency certificate from Max Hospital and the details furnished vis-à-vis the death summary.     
22. The Complainant has admitted having received the notice of these Committee meetings, and he filed these documents.  After the second STC meeting the Complainant sent an email dated 16.09.2014 to OP interalia stating that all the documents have been submitted and the admission of the patient was done in an emergency. The email also shows that complainant met Dr. Bachchan Singh and Dr. V.K. Jain at Max Hospital who told him that all documents of the patient could be obtained from the medical superintendent of the hospital. The email ID of the Max Hospital was given in the same email. OP has not refuted this email.  The Order sheets of this Commission also reflect that Complainant had again given documents to OP. It is evident that the patient was brought to the Hospital in emergency. Documents asked by STC had been submitted with the OP.  OP has not denied the same in his reply. Thereafter, Complainant has resubmitted the documents with OP, sent an email to OP and also given the documents to OP in the Commission. It is not clear as to why OP did not contact the medical superintendent of the concerned hospital to get the clarification required.  In fact, the clarification was sought with regard to the admission of the wife of complainant in emergency situation, but what clarification was sought has not been clearly mentioned/ defined. 
23. OP has passed a claim of Rs.5,11,279/- in an opaque manner without giving clarifications on the deductions. The calculation sheet filed by complainant and not disputed by OP shows that the claim of Rs.2,54,795/- is admissible. It is admitted that Rs.5,00,000/- had been reimbursed by insurance company and the net payable would be Rs.1,55,000/-.  Then in the next calculation sheet, it was calculated that admissible amount is Rs.5,11,279/-. Since Rs.1,55,000/- has been passed, an amount of Rs.3,66,279/- would be paid to the Complainant.  OP has admitted in its reply that in the initial calculation reimbursement from two sources has not been followed.  But the calculation sheet shows the amount paid to the complainant by the DHS/TPA/insurance Company was always being taken into consideration. 
24. As per the procedures to be followed for medical reimbursement, the documents filed by OP clearly states that full reimbursement can be allowed in a private non empanelled hospital under Emergency if, the patient was admitted for long period for a treatment of head injury, septicaemia, multi organ failure etc. It is clear from the death summary and Emergency Certificate filed by the Complainant that the patient was admitted in Emergency. She was admitted for more than one month from 22.09.2012 to 26.10.2012 and died due to Septicaemia with septic shock multiple organ failure. Though, the patient died on 26.10.2012 and the claim for Rs.1,55,000/- and Rs.3,56,277/- was passed, OP constituted a STC only in June after receipt of the legal notice. 
25. The Complainant is a retired Government employee in the autumn of his life. The facts of case itself show the claim was a genuine one and treatment was taken under compelling circumstances. OP has not clarified how the documents asked for were not required for passing greater portion of the claim but were important for passing remaining reimbursable amount of claim.
26. Hence, we find OP guilty of deficiency in service and direct it to pay Rs.1,43,721 along with 9% interest from the date of claim till realization.  We also award a compensation of Rs.40,000/-. for mental agony, harassment, physical inconvenience and stress suffered by the complaint a senior citizen and Rs.20,000/- towards cost of litigation. 

This order be complied with within 30 days from the date of receipt of the order.

Copy of the order be supplied / sent to the parties free of cost as per rules.

File be consigned to Record Room.

Announced on 19.10.2022.