The District Consumer Disputes Redressal Commission, Ernakulam, comprising President Shri D.B. Binu and Members Shri V. Ramachandran and Smt. Sreevidhia T.N., held Samaritan Heart Institute liable for deficiency in service after it failed to provide an individual bill for a ₹43,900 Elaxim 40 mg injection, preventing the complainant from obtaining reimbursement under the ESI scheme.

The Commission observed that production of the treatment bill was essential for claiming ESI reimbursement and the hospital's failure to provide the individual bill resulted in the complainant losing the reimbursement amount.

Facts:

The complainant, O. Vinod Kumar, was taken to Samaritan Heart Institute on January 25, 2017 after he suffered a fall at his workplace and was referred to a cardiologist. He informed the hospital that he had ESI coverage and would need medical bills for reimbursement. He was subsequently transferred to an ESI hospital and later admitted to Aster Medicity, Ernakulam.

According to the complainant, he had paid approximately ₹60,500 towards treatment but the hospital did not provide an individual bill for Elaxim 40 mg injection, which cost ₹43,900. The hospital allegedly stated that a separate bill could not be issued because the medicine had been purchased in bulk. Since the ESI authorities required the bill details to process his reimbursement claim, the complainant claimed that he could not receive the ₹43,900 reimbursement. He therefore approached the Commission seeking the amount along with ₹1 lakh compensation.

Contentions of the hospital:

The hospital denied the allegations, stating that the complainant had suffered a serious cardiac condition and was administered Tenecteplase (Elaxim 40 mg) as an emergency life-saving treatment. It maintained that a proper inpatient bill and breakup had been provided and that there was no deficiency in service.

Observation and decision:

The Commission rejected the hospital's contention that an individual bill could not be issued because the medicine was purchased in bulk.

It found that the complainant had sought the bill for his treatment from the hospital on several occasions, but the hospital had not provided the treatment records, including the individual bill for the medicine. The Commission observed that, where the complainant had insurance coverage under ESI, production of the bill was essential for receiving the insured amount. Since the complainant had not received the ESI benefit due to non-production of the treatment bill, the Commission found merit in the complaint.

The Commission partly allowed the complaint and directed Samaritan Heart Institute to:

• pay ₹43,900 to the complainant, being the amount lost due to non-issuance of the bill;

• pay ₹5,000 as compensation for mental trauma, agony and hardship; and

• pay ₹5,000 towards litigation costs.

The hospital was directed to comply with the order within 45 days from receipt of its copy. In case of failure, the amounts of ₹43,900 and ₹5,000 awarded as compensation would carry 9% per annum interest from the date of the order until full realisation.

Case Title: O. Vinod Kumar v. Samaritan Heart Institute

Case No.: C.C. No. 38/2019

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