Prescribing Consumption Of Milk To Patient Suffering With Ulcerative Colitis, Chandigarh District Commission Holds Max Super Speciality Hospital Liable

Brief Facts:

The Complainant was admitted to Max Super Speciality Hospital, Mohali (“Hospital”) as a Covid-positive patient and was discharged after treatment. The Hospital issued a bill totalling Rs.7,62,445.80/-, with the Complainant responsible for Rs. 1,11,851/-, while the remaining balance was covered by the Oriental Insurance Company Limited (“Insurance Company”). He was surprised and concerned over purported dietary advice given by the dietician, particularly the recommendation to consume milk at night, which he argued that it could have serious repercussions given his existing medical condition of Ulcerative Colitis. He also argued that reimbursement was only achieved after personal efforts due to the denial of cashless permission by Raksha Health Insurance TPA Pvt. Ltd.

The Complainant also challenged charges related to physiotherapy and claimed that although physiotherapy sessions were billed twice daily during their ICU stay, no such sessions were administered. He alleged that the physiotherapist merely demonstrated breathing exercises during their initial visit and thereafter only instructed the patient to continue the exercises independently. The billing for procedures labelled as "Physiotherapy of Lungs and Limbs" was disputed by him, along with numerous charges for items such as Alfa Bed, PPE kits, surgical gloves, syringes, cannulas, infusion sets, IV sets, connectors, and urine pots.

Additionally, he contested the inclusion of charges for a CT contrast which he argued was never performed. Feeling aggrieved, the Complainant approached the District Consumer Disputes Redressal Commission-II, U.T. Chandigarh (“District Commission”) and filed a consumer complaint against the Hospital, Raksha Health Insurance TPA Pvt. Ltd and the Insurance Company.

In response, the Hospital argued that the billing was conducted according to the hospital's tariff and the agreement with the insurance company. It claimed that the bill was forwarded to the insurance company, which approved a certain amount and left the rest to be paid by the patient. It disputed allegations of wrongdoing and argued that the diet chart and physiotherapy were administered under professional supervision and that there were no excessive charges.

Raksha Health Insurance TPA Pvt. Ltd, the third-party administrator, argued that it processed the Complainant's claim based on the policy terms and conditions laid out by the insurance company. It stated that deductions were made as per policy guidelines and that its role was limited to processing claims according to the insurance contract.

The Insurance Company argued that the claim was processed in coordination with the hospital and the Complainant, and the payable amount was released according to the policy terms and guidelines. It argued that deductions were made as per the policy conditions.

Observations by the District Commission:

The District Commission noted that there were several irregularities in the billing process, including charges for a dietician visit, purported physiotherapy sessions, and unjustified fees for items such as surgical gloves. Of particular concern was the dietitian's recommendation for the consumption of milk at night, a directive that could pose severe health risks to a patient with Ulcerative Colitis. It held that the absence of sufficient documentary evidence from the Hospital further strengthened the questionable nature of these charges.

The District Commission held that the advice provided by the dietitian, particularly given the patient's condition, constituted negligence and a clear deficiency in service on the part of the hospital. Moreover, the failure to substantiate the billed charges with adequate evidence suggested that there was an unjustifiable exaggeration of the medical bill. Consequently, the District Commission held that the Hospital was liable for unfair trade practices and demonstrated a deficiency in service by billing for services which were not rendered.

Therefore, the District Commission directed the Hospital to pay a compensation of Rs. 1,20,000/- to the Complainant for the loss, harassment, and mental anguish endured by the Complainant due to the hospital's deficient services and unfair trade practices. The complaint against the Insurance Company and Raksha Health Insurance TPA Pvt. Ltd was dismissed.

Case Title: V.K. Agarwal vs Max Super Speciality Hospital and Ors.

Case Number: C.C. No. 482 of 2022

Advocate for the Complainant: None (Complainant-in-person)

Advocate for the Opposite Party: Ankush Aggarwal (For Opposite Party No. 1) and Ram Avtar (For Opposite Party No. 3), None for Opposite No. 2

Date of Order: 04.06.2024

Click Here To Read Order