February-20: SETTLED IN COURT
- Posted by CERC India
- Posted in FEBRUARY
Doctor pays Rs. 3.93 lakhs for negligent surgery
Bharti Makwana was operated for fibroid removal by Dr. Pragnesh Shah of Sterling Hospital. After the surgery, she had pain in the abdomen and was told that it was because of the surgery and would subside soon. Despite fever and continuous pain, she was discharged the next day. She was rushed back to the hospital the same day in an unconscious state and had to be put on life support.
The doctor informed her that there was widespread infection and a life-saving surgery would be necessary. Before final recovery, she had to suffer pain for three years and was operated twice. A complaint was filed by Consumer Education and Research Society (CERS) before the Forum for medical negligence against Dr. Shah, the hospital and the insurance company.
The Forum ruled in favour of the complainant finding both medical negligence and deficiency in service. It directed the opposite parties jointly and severally to pay to Bharti, the cost of Rs. 3,48,567 along with 9% interest within 30 days. It also directed them to pay Rs. 35,000 towards compensation and Rs. 10,000 towards litigation costs. Â Dr. Shah complied with the order of the forum and paid the amount to Bharti.Â
Verdict
Dissatisfied with the order, the insurance company and Sterling Hospital appealed to the State Commission. The Commission observed that Dr. Shah had not preferred any appeal and had made payment to the complainant as per the Forum’s order, thereby accepting his liability. The commissioned rejected the appeal at the stage of admission.
Point of law
When a doctor, hospital and insurance company are jointly held liable to pay compensation for medical negligence and the doctor accepts liability and pays, the other parties have no standing for appeal.
[Source: The order of the Gujarat State Consumer Disputes Redressal Commission, Ahmedabad, dated 30 August 2019 on Appeal No. 110/2019]
Forum directs company to pay ‘reasonable’ mediclaim amount
Ashwin Sanghvi held a floater mediclaim policy of Rs. 5 lakhs from New India Assurance Co. In February 2018, Sanghvi was admitted to Aalok Orthocare Hospital, Ahmedabad, for surgery for Left Ear Stepesectomy. The cost incurred came to Rs. 1,00,845.
He filed a claim with the insurance company submitting all the documents. To his surprise, the claim was partially repudiated and only Rs. 53,074 was paid to him. CERS, on his behalf, filed a complaint with the District Forum for the remaining claim amount, mental harassment and injury, and legal costs.
The insurance company argued that it was liable to pay ‘reasonable’ expenses during policy period which it had done, hence there was no deficiency in service. It had deducted Rs. 47,771 towards charges for anaesthesia, OT, pharmacy, surgeon, consultant, and X-ray.
Verdict
The Forum observed that the expenses incurred by complainant were reasonable and within the scope of the policy. It directed the insurance company to pay the complainant Rs. 41,989 (after deducting Rs. 5,782 from balance of 47,771) with 8% interest. It also directed the company to pay Rs. 3,000 towards mental harassment and Rs. 2,000 towards cost of litigation.
 Point of law
An insurance company cannot arbitrarily consider charges as unreasonable and deduct them from a medical expenses claim.
[Source: The order of the Consumer Disputes Redressal Forum, Ahmedabad city (additional) dated 23 August 2019 on Complaint No. 741/2019]
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