Hyderabad Hospital to pay Rs 4.7 Lakh fine for violating CGHS rates, overcharging COVID Pnemonia patient

The issue pertains to the hospitalisation of the complainant, Mr Khan, a retired ASI employee, who was admitted to Star Hospitals in Banjara Hills from July 1 to 16, 2020, for Covid-19, pneumonia, hypertension and type 2 diabetes mellitus.

It was the case of the complainant that the Hospital, being empanalled under the CGHS scheme charged for his treatment at the rates in excess as against the government prescribed rates and excessively charged the complainant, who was a central government employee and covered under the scheme.

The complainant averred that the Hospital authorities informed the complainant that he needs to make payment for the treatment and later claim reimbursement from CGHS. Accordingly, the complainant paid a total amount of Rs11,51,974/ towards the medical expenses and hospitalization charges.

It was further averred by the complainant that he submitted all relevant documents (medical bills and medical record) to CGHS Government Officer seeking reimbursement of the amount of Rs.11,51,974/ incurred for the medical expenses and hospitalization for his Covid treatment in the Hospital.

However, after scrutiny by the concerned officials and forwarding the same to CGHS Begumpet, an amount of Rs.4,41,106 was reimbursed out of the total medical bill of Rs.11,51,974/.

On enquiring the reasons for partial settlement of the medical claim, the complainant received a letter from the CGHS- Additional Director stating that the bill submitted by the complainant was settled as per the CGHS approved rates and an Office Memorandum pertaining to covid positive cases and was further stated in the said letter that the treating hospital has not adhered to the CGHS rates applicable for room rent, investigations and procedures and covid treatment. It is the case of the complainant that the O.P. Hospital, being empanalled under the CGHS scheme has charged for his treatment at the rates in excess as against the government prescribed rates and excessively charged the complainant, who was a central government employee and covered under the scheme.

Aggrieved by the same, the patient filed a complaint with the Forum seeking relief against the Hospital.

The hospital denied the allegation and contended that the complainant never informed the hospital that he was covered under the CGHS scheme and that he was availing CGHS benefits and hence the Hospital charged him for his covid treatment in ICU as per its tariff and the complainant, paid without any objections on discharge after successful treatment in their hospital.

With the above contentions, the Hospital submitted that there is no deficiency of service/unfair trade practice on their part, and sought dismissal of the complaint.

After perusing the evidence and documents of both parties, the forum noted the following points that emerged for consideration- whether the complainant could make out the case of unfair trade practice on the part of the Opposite Party?, and Whether the complainant is entitled for the claim/compensation made in the complaint? To what relief?

It remarked that;

"A bare perusal of the statutory directions clearly show that it is imperative that the health care providers including the Opposite Hospital should charge as per the rates prescribed by the Government of India and the State Government of Telangana which has adopted the same and is in consonance with the directions and guidelines issued by the Ministry of Health and Family Welfare, Government of India. It is also pertinent to mention that the Letter dt. 04/03/2021 from the Directorate General of CGHS filed under Ex A-3 categorically stated that CGHS rates were not applied by the treating hospital for room rent, investigations, and procedures etc. and that the hospital did not adhere to the rates applicable for Covid Positive Cases."

It further noted that;

"Even assuming for a minute that the Hospital is not aware of the fact that the complainant is covered under CGHS scheme, the charges collected for his treatment under various heads as evident from the medical bills filed are in gross violation of G.O.Rt.No.248 dt.15/06/2020 issued by the Government of Telangana ( Ex A-4) read with the Proceedings The Director of Medical Education, Government of Telangana dt.09/10/2017 filed under Ex A5 and OM No.6-52/CGHS/GR Cell/2020/DIR/CGHS dt.10/07/2020 and CGHS approved rates referred in Ex A-3. Hence, this point is answered in favour of the complainant."

The Forum eventually held Star Hospitals in violation of the prescribed norms. It noted;

"In view of the above findings, it is clearly established that the complainant is covered under CGHS and that the Opposite Party Hospital is empanelled under the CGHS scheme and that charges collected for the treatment of the complainant for Covid-Pneumonia during 01/07/2020 to 16/07/2020 are in violation of the prescribed norms of the Government. As per the medical bills filed under Ex A1 and Ex B-3, following are the charges collected by the Opposite Hospital as against the CGHS approved rates mentioned in Ex A-3."

Holding the hospital guilty of deficiency in services, the forum held that the complainant was entitled to a refund of 4,77,386, along with 50,000 in compensation and another 10,000 for legal costs. It held;

" The Hospital has collected Rs.3,57,141/- in excess than the CGHS approved rates and Rs.1,20,245/- in excess than the rates prescribed in G.O. Rt.No.248 Dated:15.06.2020 i.e. in total Rs.4,77,386/-(Rupees Four Lakhs Seventy Seven Thousand Three Hundred and Eighty Six Only) in violation of the CGHS approved rates and statutory directions prevailing during the Covid pandemic. Hence, the complainant is entitled for refund of the said amount of Rs.4,77,386/- and the Opposite Party is liable to pay the same along with reasonable compensation to the complainant for the loss and mental agony."

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