Irrefutable Facts
The patient met with a road traffic accident (RTA), sustained brain injuries, and was admitted to the first hospital. The attendant requested to treat the patient under the Employee State Insurance (ESI) scheme and also extend the benefits under Rajiv Gandhi Jivandai Arogya Yojana (RGJAY), but the same was denied.
Later, the patient was shifted to the second hospital, under the care of the doctor. Initially, for the first half period of hospitalization at the second hospital, the patient was treated privately, and he had to pay the bills. Upon request of the attendant, during the later period of hospitalization, the patient was treated under RGJAY and ESI till his death.
On receiving complaints from the attendants, the regulatory authority de-empanelled both the hospitals from the said schemes.
Hospital’s Plea
The first hospital denied that the patient was refused treatment till the deposit was paid as alleged. It was pointed out that, on the contrary, a concession was given in the final billed amount.
The second hospital stated in defence that initially, the patient did not opt for treatment under the schemes; therefore, the had to incur the treatment expense. However, after request, the scheme’s benefits were extended for the second half of the treatment.
Court’s Observations
The court commented adversely on a note in the medical record which mentioned that “relatives of the patient have been informed of various government schemes, and they are ready to incur the expenditure privately as the patient was in a serious state”.
The court observed that the patient was brought in a serious condition and under such circumstances, “relatives of the patient may not be in the condition of choosing any particular scheme for the treatment”, otherwise also “why the relatives opt for private expenditure when a particular scheme is available for meeting the expenditure for treatmen”.
The court concluded that it was the duty of the doctor and the hospital to enquire and inform the patient and the attendants about any such schemes.
The court observed that the second hospital had extended the scheme’s benefits for the second half of the treatment after receiving a request from the attendant. The court commented that it was also possible for the second hospital to reimburse the expenditure for the first half of hospitalization.
The court held that it was an “administrative issue and not a technical issue or treatment issue” on part of the doctor and hospital.
Prevention Is Better Than Cure
Hospitals / doctors should proactively enquire with the patients / attendants whether they are covered / eligible under any government scheme for reimbursement of expenses or subsidized / free treatment. This exercise is rather mandatory before admitting a patient. Courts may draw adverse inferences against the hospital / doctor for not giving benefits under these schemes to eligible patients, as illustrated in this case.
Source : The Manager, Dunakhe Hospital v/s Ashok Shantavan Alhat & Ors.
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