Complainant by filing this complaint has submitted that he joined with the scheme as invited by the appropriate authority of United Bank of India (UBI) for Mediclaim Insurance Scheme for Retired Employees of UBI vide UBI Circular No.PD/DIR/30/OM-0800-2012 dated 23.03.2012.  Accordingly he sent application in proper format along with the remittance of Rs.3,500/- for the yearly premium for the year 2012-13 in favour of Bajaj Allianz General Insurance Co. Ltd. by crediting their A/c No.0389050192231.

          Accordingly op Bajaj Allianz General Insurance Co. Ltd. issued him two Health & Wellness Card vide Policy No. OG-13-2401-8403-00000006 valid upto 31.03.2013 in the name of Kiran Sankar Roy, ID. No.UBR-13-2482 and in the name of his wife Smt Sabita Ray, ID No. UBR-13-2482A valid up to 31.03.2013.  In the meantime UBI had renewed the arrangement with Bajaj Allianz General Insurance Co. Ltd. and they were agreed to provide Mediclaim Insurance benefits by way of reimbursement of hospitalization expenses to retired employees as per the scheme elaborated in the said circular.

          On 25.03.2013 Sabita Roy was admitted to M.V. Hospital for Diabetes and other complications at Chennai under Dr. Vijay Viswanathan with a complaint of occasional Giddiness, constipation, right sided weakness and also assessment and control of diabetes mellitus etc.  On admission the doctor has started diagnosis and other investigations and after investigation and treatment she became stable and was released and complainant Kiran Sankar Roy paid entire treatment cost and other charges of Rs.18,997.30 paisa and thereafter complainant submitted claim according to the format of Bajaj Allianz Health Insurance claim form of op in which along with hospital bill in original.  But op insurance company refused to reimburse the said bill vide their letter dated 08.04.2013 on the plea that the complainant was hospitalized for investigation for Type II Diabetes Mellitus with Hypertension with Hypothyroidism and not for any treatment and no related treatment was made and being aggrieved op sent further letter and requested them to re-consider, but that was also rejected on the plea that the said claim is not permissible as per clause of the contract.

          So, in the circumstances for unfair trade practice and for not properly assessing the reimbursement of the claim, complainant has prayed for relief.

          On the other hand op by filing written statement submitted that the op provided cover subject to specific terms and conditions as stipulated in the policy, which governs the instant claim and further the wife of complainant had been diagnosed for Type-II Diabetes Mellitus, Hypertension, Dyslipidemia, Diabetic Retinopathy, Hypothyroidism with Acid Peptic Disease and no doubt she was admitted to M.V. Hospital for some examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at a Hospital/Nursing Home.

          So, Insurance Company after careful examination the same and also other documents arrived at the conclusion that the claim is not payable as the claim does not fall under the purview of the policy and it falls under the Exclusion Clause No.4.10 of the policy terms and for which there was no laches or negligence on the part of the op and in any case op never adopted any unfair trade practice and for which the complaint should be dismissed.

                                                     Decision with reasons

          On proper evaluation of the argument as advanced by the Ld. Lawyers of both the parties and also considering the evidence and including the documents as well as the complaint and written version, it is clear that complainant filed a bill for reimbursement of the treatment of his wife at M.V. Hospital for Diabetes (P) Ltd.- Royapuram at Chennai being claim No.OG-13-1002-8403-00044032.  But the said claim was repudiated on the ground that she was hospitalized for investigation for Type II Diabetes Mellitus, Hypertension, Dyslipidemia, Diabetic Retinopathy, Hypothyroidism with Acid Peptic Disease and claim was repudiated as there was no such treatment as administered or no investigation was being performed which supports the need for hospitalization.

          So, moot question is whether hospitalization was necessitated for any investigation of treatment or not in respect of the patient.  Because op has not denied that patient is cover under the policy rather it is admitted fact that complainant and his wife are covered by the present insurance policy and there is no question of exclusion in respect of pre-existing disease in view of the terms and conditions of the policy.  But we have now considered whether such observation for repudiation is based on medical theory or not.  In this regard we have gone through the report of the said doctor and fact remains on 25.03.2013 Sabita Roy was feeling right sided weakness, giddiness and constipation when he appeared before that hospital and doctor of hospital authority after checking up advised for hospitalization for further evaluation for right sided weakness and as per doctor’s advice she was hospitalized on 26.03.2013 where several type of diagnosis were done and several type of investigations were made and thereafter doctor found that there was some Infero lateral Ischaemia for which TMT was advised and to control the same, Statin Therapy was followed and he was also advised to consult with Neurologist as early as possible.

          Further TSH was found to the above normal limit, so Anti TPO, Anti body was sent and urine for malignant cells is also sent  as she was on pioglitazone for a considerable period of time.  Further it was found that there Proliferative Diabetic Retinopathy in both eyes and after giving proper medicine and other treatment she became stable and she was advised to do the same and after admission she was treated with Glimepiride, Metformin and Vildagliptin and thereafter she responded well.

          So, considering the treatment sheet and discharge summary it is clear that practically she was a patient of Hypertension and sugar.  At the same time it was detected that she was suffering from Ischeamia heart and for which Statin Therapy was followed.  Thereafter she responded well and her giddiness and right sided weakness was controlled and she was stable and thereafter completing all other treatments she was released.

          Fact remains that she had been suffering from right sided weakness and it was due to Infero Lateral Ischemia and to control that situation that time Statin Therapy was followed and some other medicines were given to control her blood sugar and pressure and thereafter the doctor found that she was able to that extent but at the time of release she was advised to take certain drugs as per advice and also advised for checkup after two months.

          In the meantime she had been asked to do TMT as far as possible to do some other investigations.  So, it is clear that at the time or prior to admission practically the lady aged about 54 years old was suffering from right sided weakness and invariably in such a case no doctor shall have to give any advice to go such a patient to her house and to take rest in her bed but it is the symptom of her ailment and practically her ailment was detected and for which the treatment was given by the doctor at M.V. Hospital at Chennai and after Statin Therapy she recovered from such weakness that is right sided weakness but other treatment was highly required for which certain further investigation was done and at the relevant time it was found stable after treatment she was released to review after two months after taking such subsequent medicines as per advice as given in the discharge summary.  Then how we can say that no treatment was done. 

          It is to be mentioned in this regard that not a single doctor shall have to start a treatment in respect of any patient if it is found that she/he has been suffering weakness of any portion of the body because it is suspected that any weakness of any portion of the body is related to any heart problem.  So, before that all type of investigations are required and in the present case that was done.  Moreover it was done on the ground that the patient was known case of Hypertension and Blood Sugar.  So, treatment cannot be started or a medicine cannot be given without any further diagnosis.

          So, all possible tests, diagnosis were done and thereafter the doctor pointed out what diagnosis they have done and it was found that the lady has been suffering from several type of diseases out of which particular serious position in respect of Infero Lateral Ischeamia for which Statin Therapy was followed.  Then how op decided that no treatment was given.  No doubt the private insurance companies are born only for the purpose for collecting the premium not for giving any coverage to the mediclaim insured and it is the common practice in almost all the cases what we have gathered at the time of handling of such sort of cases daily.

          But we have failed to understand why they are adopting such a path for repudiating the claim.  Whatever it may be after giving an introspective study in respect of other mediclaim documents, we are confirmed that there was excessive necessity for admission without admission several types of tests and investigations and diagnosis  and treatment cannot be done.  So, it was not casual tests but Statin Therapy was followed as it is found that she was suffering from Ischeamia of heart.  But anyhow after giving proper treatment, medicine and Statin Therapy etc. she became stable and was discharged advising the patient to report after two months after taking such medicines and for further checking up other points as already noted down in the said discharge certificate.

          So, considering the fact we are of  view that check-up and treatment were done but most probably the authority of private insurance companies are no doubt adopted a nonsense decision and repudiated the same only for the purpose of creating capital of the insurance company and for which they have without any reasonable and moral ground repudiated the claim and that repudiation is no doubt arbitrary and without any medical foundation.  So, under any circumstances, the said treatment does not come under the purview of exclusion clause as pointed out by the op.  but we have confirmed that as per policy conditions, the present patient is entitled to get mediclaim benefit as there is coverage and the policy is a valid policy and claim is in continuation.

          So, the complainant is entitled to get such amount for the treatment of his wife as mediclaim benefit from the op insurance company and op insurance company is legally bound to pay it and it is further observed that repudiation as made by the op insurance company is without any medical foundation and arbitrary in nature.

          In the result, the complaint succeeds.

Hence, it is

                                                            ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs.5,000/- against the op.

          Op is hereby directed to pay Rs.18,998/- to the complainant as reimbursement of the Mediclaim as submitted by the complainant treating the said claim as finally disposed of and it must be paid within one month from the date of this order to the complainant and further for causing harassment and mental pain and agony op nos. 1 & 2 insurance company shall have to pay compensation to the extent of Rs.5,000/- to the complainant within that period.

          Op nos. 1 & 2 are hereby directed to comply the order within one month from the date of this order by clearing the entire dues and compensation, litigation cost within one month failing which for non-compliance of the Forum’s order and for each day’s delay op no.s 1 & 2 jointly and severally shall have to pay @ Rs.300/- per day till full satisfaction of the decree and if it is collected it shall be deposited to this Forum.

          If ops are found reluctant to comply the order of this Forum and also for disobeyance of the order penal action shall be started against them for which further penalty and fine may be imposed and for which op nos. 1 & 2 shall be liable.

          But the present complaint against the op/Bank is dismissed without any cost.