Apollo Hospitals Held Liable for not Charging CGHS Rates, slapped compensation

Visakhapatnam: The District Consumer Disputes Redressal Commission-I, Visakhapatnam recently held Apollo Hospitals liable for offering treatment to a former Union Government Gazetted Officer at an exceeding rate and later failing to refund the excessive amount collected over and above the prefixed rates under the Central Government Health Scheme (CGHS).

While the hospital charged Rs 15,82,894 from the complainant, who underwent treatment for accidental burns, the Government reimbursed the claim of the complainant based on the medical bills issued by the hospital. They determined that out of Rs 15,82,894 charged by the hospital, Rs 9,94,102 was eligible as per the prefixed rate.

Therefore, holding Apollo Hospitals, Visakhapatnam deficient in service, the consumer court directed it to pay Rs 5,88,793/- to the complainant along with interest @ 7.5% p.a. from the date of Complaint i.e. 03.09.2021 till the date of realisation. Further, the hospital was directed to pay Rs 25,000/- towards compensation for mental agony and Rs 10,000/- towards costs.

The matter concerned the complainant, who is a retired Government Gazetted officer. Being an employee of the Government of India, is entitled to the terminal benefits besides privilege of using medical facility to herself and her husband. In this regard, the Central Government issued health cards by virtue of which, the complainant is entitled for cashless treatment at Apollo Hospitals.

Back in 2019, the complainant met with an accident and was taken to Apollo Hospital. The hospital staff, provided first aid to the complainant and advised her to get special treatment for burn injuries requiring special equipment. Accordingly, the complainant got admitted to the hospital in the Intensive Care Unit and deposited Rs 70,000 as an initial amount. 

Allegedly, the hospital collected the said amount even though the complainant informed that she was a beneficiary under the CGHS. Finally, after an alleged delay of 2 days, the treatment commenced and after around 1 month, the patient was discharged from the hospital. The hospital allegedly collected Rs 15,62,895 from the complainant promising that she have a right to recover the said amount from the Government.

After being discharged from the hospital, the complainant approached the Government seeking a refund of the amount incurred by her in the hospital. After making necessary inquiries with the hospital, the Government paid an amount of Rs 9,94,102 out of Rs 16,82,894 by way of cheque.

It was contended that the Government after making the payment to the complainant served show-cause notice seeking for explanation. The complainant alleged that as a result of the show-cause notice, the hospital deliberately violated the terms of agreement entered into between the hospital and the Government.

The complainant argued that since the Government did not redress the grievance of the complainant, both the hospital and the Government authorities are jointly and severally liable to pay the amount claimed in the complainant. Filing the complaint, the patient prayed for a direction upon the hospital and the Government authorities to pay Rs 5,813,793 for compensation of Rs 10 lakh and another Rs 10,000 towards costs.

In the complaint, the patient contended that the conduct of the hospital is unlawful by not following the rates prescribed and agreed by it with the Government authorities. The complainant further argued that there was deficiency on the part of the Government as it could not recover the excess amount from the hospital.

On the other hand, the hospital alleged that the complainant committed breach of fundamental obligation in disclosing that the Complainant is a beneficiary of CGHS. Further, the complainant allegedly did not submit authorisation letter issued by the Chief Medical Officer of the concerned CGHS dispensary or the production of ID card which is mandatory as per the agreement entered with the Government on 07.11.2017, which was valid till 06.11.2019. 

Further, the hospital submitted that it provided treatment in good faith and that there was no wilful deficiency on their part. The hospital argued that there was no reason in not extending the credit facilities except for the fact that the complainant did not disclose about her entitlement and paid all amounts for the treatment given to her without any demur. 

Contending that it has no role in settlement of the claim made by the complainant with the Government authorities, the hospital further submitted that the amount that was deducted by the authorities included non-admissible items like toiletries, sanitary napkins, and other dietary supplements.

Meanwhile, the Government authorities submitted that the complainant's claim was processed as per the CGHS tariff and the admissible amount was reimbursed to the complainant. Further, the authorities submitted that they have no role in the excess charges collected by the hospital. 

It was further submitted that the hospital failed to provide credit basis treatment to the complainant as per the terms of agreement and due to this, the hospital was removed from the CGHS empanelled list of hospitals for violating the terms of agreement.

While considering the matter, the consumer court noted that the Government of India introduced CGHS scheme with an intention to provide comprehensive medical care facilities to the Central Government employees/pensioners.

As per the scheme, the beneficiaries can avail cashless medical facilities in any of the panel hospitals. For convenience of the employees, the Central Government empanelled renowned hospitals in the country and Apollo Hospital is one of them. 

Further, the Commission noted that the President of India acting through the Additional Director of CGHS, Ministry of Health, entered into an agreement with Apollo Hospital on 07.11.2017 which was valid for two years. In terms of the agreement, the hospital has to provide treatment/facilities to the CGHS beneficiaries. In case of pensioners under the CGHS scheme, the healthcare centres shall provide treatment on credit basis. 

Referring to the case of the complainant, the Commission noted that the hospital provided emergency treatment to the complainant in their hospital for accidental burns from 27.10.2019 to 30.11.2019. For this, the hospital collected Rs 15,82,894 from the complainant.

"As on the date of commencing of the treatment, the agreement entered with OP-3 is in force. Yet OP-1 collected the amount surpassing the terms of agreement when the complainant has not received the treatment on credit as per her entitlement, after her discharge she lodged claim with OP-2 for reimbursement of the amount incurred by her. Opposite Parties 2 & 3 instead of reimbursing entire claim going by the bills issued by OP-1, allowed part of the claim without assigning the reason," noted the Commission.

"Even according to the admissions made by OP-1 a sim of Rs 15,82,894/- was charged from the complainant for providing treatment for accidental burns. Had the OP-1 provide the said treatment to the Complainant on credit basis in terms of the agreement subsisting between them, OP-1 would have charged Ts 9,94,102/- which was reimbursed by OP-2 to the complainant, since the rates are prefixed between OP-1 & OP-3. So the amount that the collected over and above Rs 9,94,102/- is applicable to the general patients as per the medical protocol as contended by OP-1," the Commission further observed.

The consumer court took note of the fact that the hospital indisputably collected Rs 15,82,894 from the Complainant towards treatment charges and this amount is stated to be applicable to general patients as per Medical protocol. By then, the hospital allegedly did not know that the complainant was a beneficiary under te CGHS scheme, noted the Commission.

"OP-1 being one of the panel hospital under CGHS should have returned the amounts to the Complainant collected over & above the prefixed charges in terms of the agreement entered with OP-3. Since, OP-2 reimbursed the claim made by the Complainant based on the medical bills issued by OP-1. They have determined that out of Rs 15,82,894/- charged by OP-1, Rs 9,94,102/- is eligible as per the prefixed rate. OP-2 issued notice to OP-1, on receipt of representation from Complainant. A legal notice was also issued to OP-1 by Complainant claiming refund of excess amount of Rs 5,88,793/- collected from the Complainant in violating of the terms of the agreement," the Consumer Court observed.

"The OP-1 being panel hospital bound to provide treatment to the beneficiary (Complainant) on credit as per agreement, failure to adhere the terms of the agreement and return the amounts collected over and above the prefixed rates from the Complainant amounts to deficiency in service," it opined.

With this observation, the Commission directed the hospital to return Rs 5,68,793 to the complainant with interest as charged by the nationalised banks. "It is relevant to mention here that not providing treatment on credit basis and charging excess amounts from the Complainants definitely cause mental agony for which she deserves reasonable amount as compensation," it further noted.

"In the result, the Complaint is allowed in part directing the 1st Opposite Party to pay Rs 5,88,793/- (Rupees Five lakhs eighty eight seven hundred and ninety three only) with interest @ 7.5% p.a. from the date of Complaint i.e. 03.09.2021 till the date of realisation and further directed to pay Rs 25,000/- (Rupees Twenty five thousand only) towards compensation for mental agony and Rs 10,000/- (Rupees Ten thousand only) towards costs," ordered the consumer court.

To view the order, click on the link below:

https://medicaldialogues.in/pdf_upload/visakhapatnam-consumer-court-229070.pdf

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