(The 1st Respondent as complainant filed a complaint before the District Forum against the opposite parties praying for the direction to the opposite parties to pay the assured sum of Rs.10000/- as compensation. The District Forum allowed the complaint. Against the said order, this appeal is preferred praying to set aside the order of the District Forum dt.29.10.2008 in CC.No.688/2004.
This petition coming before us for hearing finally on 17.08.2011. Upon hearing the arguments of the counsel on both sides, perusing the documents, lower court records, and the order passed by the District Forum, this commission made the following order:)
M. THANIKACHALAM J, PRESIDENT
1. The 3rd opposite party is the appellant.
2. The complainant/ 1st respondent, in this appeal, had taken a mediclaim policy, with the 1st opposite party, and on that basis, a cashless credit card facility was issued by the 2nd opposite party, for taking treatment in the empanelled hospital including the 3rd hospital also. On 20.3.2004, the complainant had severe chest pain, uneasiness, and therefore rushed to the 3rd opposite party hospital at 4.30 p.m, where the duty doctor directed the complainant to go to ICU , where medical checkup was done, informing the elevated BP, not a good sign. Before proceeding to the hospital, the complainant also informed the 2nd opposite party, for authorization.
3. The 3rd opposite party, despite request of the complainant for admission, refused to admit him in the hospital, insisting payment of Rs.20000/-, and complainant was unable to pay the said amount reasonably, he was compulsorily forced to discharge from the hospital at 10 p.m. The matter was reported to the authorities concerned, no action has been taken Though the 3rd opposite party had collected a sum of Rs.980/-, treating the complainant, as out patient, the denial of the 3rd opposite party, to admit and give treatment as inpatient, should be construed as negligence and deficiency of service, which had caused mental agony, for which the complainant is entitled to a sum of Rs.1 lakh, as compensation. Thus claiming a consumer complaint was filed.
4. The opposite parties 1 and 2, admitting that the complainant had been to the hospital, resisted the case interalia contending, that the patient was not hospitalized, as there was no need for the same, and therefore there was no negligence or deficiency on the part of the opposite parties, in not settling the alleged claim, thereby prayed for the dismissal of the complaint.
5. The 3rd opposite party, admitting that the complainant came to their hospital on 20.3.2004 at 4.35 p.m, complaining chest pain, vomiting and giddiness, resisted the case contending that after monitoring the condition of the complainant, he was advised to get admitted as inpatient, that because of the 2nd opposite party’s office closing hours, they were unable to obtain the approval of the 2nd opposite party, and under the said circumstances alone, the complainant was requested to deposit a sum of Rs.10000/-, that could be returned to him, after obtaining approval, this cannot be treated as deficiency in service. The complainant, in order to extract money, without merit filed the case, which is liable to be dismissed.6. The District Forum, based upon the affidavits, as well as the admission of the 3rd opposite party, came to the conclusion, that the 2nd and 3rd opposite party alone have committed deficiency, and in this view, directed them to pay a compensation of Rs.25000/- to the complainant, jointly and severally, as per order dt.29.10.2008, which is under challenge.
7. The complainant had taken a mediclaim policy, with the 1st opposite party, not disputed, for which a cashless health card was issued, as seen from Ex.A3, an admitted fact. The very purpose of issuing this kind of health card, is to enable the card holder, to take treatment in the listed hospital, not only for elective surgery, but also for emergency hospitalization, without paying the actual amount, and that is why there was an understanding between the hospitals and the opposite parties 1 and 2. The 3rd opposite party is an empanelled hospital is an admitted fact, which is also seen from ExA5. Therefore, if a person i.e. health card holder, comes to the hospital, that too for emergency treatment, he should be admitted without insisting cash payment, failing which, that should be construed as negligence, deficiency in service, as rightly held by the District Forum, in this case.
8. The case of the complainant is that he went to the hospital of the 3rd opposite party on 20.3.2004 at 4.35 pm., because of the severe chest pain and giddiness, which is admitted by the 3rd opposite party, in the written version paragraph 4. It is also admitted by the 3rd opposite party, that his health condition was monitored for 3 hours, and thereafter he was advised to get admitted as in patient, thereby indicating that hospitalization was a must, because of the emergency. But unfortunately, as per the general condition of the policy, pre-authorisation was not given by the 2nd opposite party. Therefore, as pleaded in paragraph 4 of the written version, the complainant was directed to deposit a sum of Rs.10000/-, in order to admit him in the hospital, for further treatment, which the complainant refused, legitimately also, being an health card holder, entitled to take treatment, without paying the amount, then the hospital should claim from the opposite parties 1 and 2, as per the understanding between themselves, based upon the mediclaim policy. In this context, we have to see whether pre-authorisation is necessary in the case of emergency.
9. As seen from the conditions in the health card policy, hospitalization requires pre-authorisation generally, and without pre-authorization by the 2nd opposite party, the empanelled hospital can refuse to admit the card holder as inpatient, and give treatment, which cannot be faulted. As far as the emergency hospitalization is concerned, the procedure is different, which can be seen under the heading emergency hospitalization in Ex.A2, which reads 'the policy holder is advised to get admitted. In case of admission to a Network Hospital the hospital will admit the patient as per the procedure of the hospital. The hospital will then contact TTK and send us a request for authorization. At times the policyholder may be required to contact TTK for authorization', only thereafter i.e., admission, the policy holder should send the pre-authorisation request, completely filled and not before that. In view of the understanding between the empanelled hospital, and the opposite parties 1 and 2, in our considered opinion, the network hospital viz. 3rd opposite party, should have admitted the complainant, as per their procedure, not insisting payment. But admittedly, the 3rd opposite party as pleaded in the written version, insisted to deposit the amount, and inspite of the prior intimation to the 2nd opposite party, they have also failed to contact the 3rd opposite party, failed to advise them to admit the complainant and to give treatment, because of the emergency situation. In the bill itself, i.e., Ex.A5, the complainant was treated in emergency, since it is said 'causality medical officer and emergency'. When the complainant had come to the hospital/3rd opposite party, for chest pain, having giddiness and vomiting sensation, the opposite party should have admitted and mercilessly insisting for deposit, violating the terms, discharged him after 5 hours or so, which is in our o
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pinion, a negligent act, committed by the 3rd opposite party, followed by deficiency in service, in medical profession, for which they should be held responsible, as rightly held by the District Forum. The 2nd opposite party has not challenged the order. The 3rd opposite party having committed negligence, as well as deficiency, in not admitting the complainant, insisting payment, should have caused mental agony, compelling him to take treatment, that too in the emergency situation. Considering all these fats, the order of the District Forum, awarding Rs.25000/- as minimal, does not warrant any interference. Hence the appeal is devoid of merits, liable to be dismissed. 10. In the result, the appeal is dismissed, confirming the order of the District Forum in CC.688/2004 dt.29.12.2008. There will be no order as to cost in this appeal.