Order No.  16  dt.  23/03/2017

       The case of the complainant in brief is that the complainant is a mediclaim policy holder under o.p. no.1 and while she was suffering from gastritis she requested the o.p. nos.1 and 2 for cashless claim for the treatment of her illness and she was admitted in the nursing home and o.p. insurance company sanctioned a sum of Rs.25,000/- on 23.12.13 for the treatment of acute gastritis. While the complainant being treated the said nursing home diagnosed of having fibroid uterus other than acute gastritis and accordingly the complainant prayed for enhancement of the cashless amount but o.p. nos.1 and 2 denied the cashless facility stating that the said ailment is not covered in the 1^st two policy years. Since the condition of the complainant was serious she had to pay total bill of Rs.56,176/- to o.p. no.3. The complainant repeatedly requested the o.ps. for reimbursement of the medical bill but the same was denied for which the complainant sustained huge financial loss. In view of such fact the complainant prayed for an amount of Rs.56,176/- towards the medical bill paid by the complainant as well as compensation of Rs.2 lakhs and litigation cost.

            The o.p. nos.1 and 2 contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that just after admission before o.p. no.3 one cashless claim intimation was intimated to o.p. nos.1 and 2 and as such, cashless authorization of Rs.25,000/- was sanctioned by o.p. nos.1 and 2 in favour of the complainant. Subsequently in course of treatment when it was detected that she was also suffering from fibroid bulky uterus, hence such cashless claim authorization was withdrawn at that point of time as per condition C1 of the policy. Clause C1 of the policy provides that any medical expenses incurred during the 1^st two consecutive period during which you have the benefit of a health card policy with the insurance company in connection with any type of gastric, duodenal ulcer and others. This exclusion period shall apply for a continuous period of full four years from the date of the 1^st health card policy and if the above referred illness was present at the time of the policy and if the policy holder had declared such illness at the time of proposing the policy for the first time. In case of enhancement of the sum insured the waiting periods shall apply afresh only to the extent of the amount by which the limit of indemnity has been increased i.e. enhanced sum insured if the policy is a renewal of health policy without break in cover. It was stated that as per the policy in the 1^st without continuity, the claim is of fibroid uterus there is a waiting period of two years for the fibromyomas and dysfunctional uterine bleeding, accordingly the claim was denied. In view of such facts o.ps. prayed for dismissal of the case.

            In spite of receipt of notices the o.p. nos.3 and 4 did not contest this case by filing w/v and as such the case has proceeded ex parte against them.

            On the basis of the pleadings of parties the following points are to be decided:

1. Whether there was any policy under the o.p. insurance company.
2. Whether the existing policy can give the benefit to the complainant for reimbursement of the medical bill in respect of another disease after the enhancement of the insured sum.
3. Whether there was any specific period for which the complainant will be able to avail of the benefit of the policy.
4. Whether there was any deficiency in service on the part of o.ps.
5. Whether the complainant will be entitled to get the relief as prayed for.

Decision with reasons:

            All the points are taken up together for the sake of brevity and avoidance of repetition of facts.

            Ld. lawyer for the complainant argued that the complainant had the policy at the relevant point of time and with the ailment of gastritis she was admitted to the nursing home and for availing of the cashless facility o.p. nos.1 and 2 were informed and the facility was provided. During the period of undergoing treatment the nursing home diagnosed of having fibroid uterus of the complainant for which the treatment was also rendered. After the treatment the complainant submitted bills for reimbursement of the amount of Rs.56,176/- but the said claim was repudiated by o.p. insurance company for which the complainant filed this case praying for direction upon the o.ps. to pay the medical bills paid by the complainant as well as for other reliefs.

            Ld. lawyer for the o.p. nos.1 and 2 argued that where the ailment with which the complainant was admitted in the nursing home for the relevant period was at all covered during the 1^st two years of the policy period or not. Here in this case, the policy was valid during the period from 30.6.13 to 29.6.14 and this is the 1^st policy of insurance and the complainant spent a sum of Rs.56,176/- for her treatment for the relevant period. From condition no.C2 of the terms and conditions of the policy it is clearly stated that any type of fibromyomas and dysfunctional uterine bleeding and several other diseases were not covered during 1^st two years of the inception of the policy. Since from the discharge certificate it appears that the complainant suffered from the said illness, therefore both the diseases were not covered during the 1^st two years of the policy and the repudiation of the claim of the complainant was not deficiency in service on the part of o.p. nos.1 and 2. Thought the complainant claimed that she was suffering from gastritis but the bill submitted to the TPA established the fact that she was suffering from the diseases relating to fibromyomas and dysfunctional uterine bleeding which are not covered during the 1^st two years of insurance policy. In view of such fact ld. lawyer emphatically argued that the claim of the complainant was rightly repudiated by o.p. nos.1 and 2, therefore the complainant will not be entitled to get any relief as prayed for.

            Considering the submissions of the respective parties it is admitted fact that the complainant was admitted to the nursing home and she underwent treatment and it is also an admitted fact that the policy was valid at the relevant point of time. Initially after the intimation given to o.p. nos.1 and 2 a cashless facility of Rs.25,000/- was sanctioned, but subsequently with the submissions of the medical papers and on scrutiny of the medical papers it was detected that the sufferings made by the complainant for the disease not related to gastritis but she was actually suffering from fibromyomas and dysfunctional uterine bleeding which were not covered during 1^st two years of insurance policy. As per clause C2 of the policy condition debars the complainant to claim any amount on the ground of those diseases within the two years from the date of opening of the policy by the insured.

            In this respect we can rely on a decision as cited by ld. lawyer for o.ps. reported in AIR 1999 SC 3252 that the insured cannot claim anything more than what is covered by the insurance policy. That being so, the insurer has also to act strictly in accordance with the statutory limitation or terms of the policy expressedly setout therein. Here in this case, in the policy itself it was mentioned that within the period of two years from the date of policy the complainant will not be able to reimburse the bills for the disease as mentioned in the policy itself. Therefore we hold that there was no deficiency in service on the part of o.ps. and accordingly, the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.

            Hence, ordered,

            That the CC No.394/2014 is dismissed on contest against the o.p. nos.1 and 2 and dismissed ex parte against other o.ps. without cost.            

            Supply certified copy of this order to the parties free of cost.