<br /> O R D E R <br /> <br /> <br /> SRI. D.KRISHNAPPA., PRESIDENT., <br /> <br /> The grievance of the complainant against the Ops in brief is that he is an employee of a company which had taken corporate health insurance cover for all its employee’s and he has been issued a policy for the period covering from 1-06-2008 to 31-05-2009. That he had sleeping dis-order as such consultant Dr.H.V. Suryanarayana of Jain Hospital, Bangalore conducted sleep study test on 09-01-2009 till 10-01-2009 for a period of 8 hours 49 minutes and he was diagnosed as suffering from severe obstructive sleep apnoea as the CPAP Polysomnography report and Dr. M.Ramesh recommended that he should be treated with Auto C Flex CPAP 13CM H20 and he was recommended to use CPAP regularly to prevent long time complications and stated that CPAP equipment is a life saving instrument. That he accordingly purchased the equipment on 27-01-2009 by paying Rs.62,000/- and has also incurred hospital expenditure of Rs.12,540/-, in all he incurred Rs.74,540/- . Then he made a claim with the OP 2 who is the administrator whose service is engaged by OP 1 the insurance company to settle insurance claims. But the 2nd OP has repudiated the claim by quoting clause 4.9 of the policy and therefore attributing deficiency in the service of the OP has prayed for a direction to the Ops to reimburse Rs.74,540/- , to award compensation of Rs.25,000/- for mental agony and pass other orders.<br /> <br /> In response to the notice issued on this compliant OP 1 has appeared through his advocate and contested the claim whereas OP 2 has not contested the complaint.<br /> <br /> OP 1 in his version without disputing the issue of the policy in favour of the complainant admitted that OP 2 is their 3rd party administrator, has justified the action of OP 2 in repudiating the claim of the complainant for reimbursement of medical expenditure. It is further contended that OP 2 has repudiated the claim of the complainant by following due procedure and do not amounts to deficiency in their service. That as per the terms and conditions of the group medical insurance policy, clause 2.2 under the head hospitalization benefits means expenses of hospitalization for minimum period of 24 hours which are admissible. The OP further reproducing clause 2.2 of the conditions of the policy has stated that the complainant is not entitled for reimbursement, and sleeping disorder is not at all a disease as per the exclusive clause 4.9 and other diagnosing charges are not consistent and therefore has prayed for dismissal of the complaint. <br /> <br /> In the course of enquiry into the complaint, the complainant and Assistant Manager of legal claims of OP 1 have filed their affidavit evidence reiterating what they have stated in their respective compliant and version. Complainant has produced copy of policy, report of Bhagwan Mahaveer Jain hospital where he underwent treatment, copy of the bills and a copy of repudiation letter issued by OP 2. OP 1 has produced a copy of the policy with a copy of terms and conditions of the policy in question. Heard the counsel for both the parties and perused the records. <br /> <br /> On considerations of the above, following points for determination arise.<br /> <br /> 1. Whether the complainant proves that the OPs have caused deficiency in their service in not reimbursing his medical expenditure? <br /> <br /> 2. To what relief the complainant is entitled to ?<br /> <br /> Our findings are as under:-<br /> <br /> Point No: 1 in the affirmative. <br /> Point No: 2:see the final order.<br /> <br /> REASONS: ANSWER POINT No:1:: Having understood the complainant as an employee of a private company was issued with corporate Health insurance cover covering the period from 1-06-2008 to 31-05-2009 and that the complainant underwent some diagnosis and treatment between 09-01-2009 to 10-01-2009 and there being no other controversy with regard to the material facts, we shall consider whether the repudiation of the claim of the complainant by the OP 2 the 3rd party administrator of OP 1 is justified and is sustainable. <br /> <br /> OP 2 the administrator of OP 1 has not contested the claim of the complainant. OP 2 found to have turned down the claim of the complainant for reimbursement by quoting clause 4-9 of conditions of the policy. Clause 4.9 of the conditions of the policy fall within the exclusions of the policy which reads as under:<br /> <br /> “Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies 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 or at home under domicillary hospitalization as defined”<br /> <br /> <br /> Reading this exclusion conveys that the insured is not entitled for reimbursement of the expenditure made for diagnosis, studies and examinations which are not consistent with or incidental to the diagnosis and treatment of the existing or prevailing ailment. That means to say this clause excludes expenditures incurred by the insured towards tests which are not consistent with the prevailing ailment. But in the case on hand it is not in dispute that the complainant underwent or subjected to the test by the doctors to study the sleeping dis-orders of the complainant. Therefore Ops cannot repudiate the claim of the complainant by invoking this exclusion. The 1st OP in his version and affidavit evidence has contended complainant is not entitled for reimbursement as per the policy clause 2.2. Clause 2.2 of the conditions of policy speaks of hospitalization benefits. Clasue 2.2 comes within the definition clause and it only speaks of or gives definition of hospitalization benefits. Which means that hospitalization expenses will be reimbursed only when the insured hospitalized for a minimum period of 24 hours. But still, under these hospitalization benefits certain tests or surgeries are excluded from the minimum requirement of 24 hours hospitalization. However the policy conditions provide for reimbursement of relevant medical expenses during the period upto 30 days prior to hospitalization under clause 3.1 of conditions of the policy. Therefore considering all these conditions of the policy as brought to our notice we find that wholesale repudiation of the claim of the complainant by Ops is erroneous and it amounts to deficiency. <br /> <br /> On perusal of the medical record produced by the complainant we find that he was admitted to an hospital on 09-01-2009 and was discharged on the next day that is on 10-01-2009 and as admitted by the complainant himself he was hospitalized for 8 hours 49 minutes only. Therefore he was not an in-patient for a minimum period of 24 hours as contemplated under clause 2.2. of the conditions of the policy. The complainant do not also fall within the exceptions of that clause as such the complainant will not be entitled for hospitalization expenditure amounting to Rs.8360/- which is charged by Bhagawan Mahaweer Jain hospital. However the complainant will be entitled for reimburse of sleep study test for Rs.4000/- and Rs.180/- towards consultant charges in additional to Rs.62,000/- he has spent for the purchase of CPAP equipment. The discharge summary of the hospital and recommendation disclose that the complainant must be treated with Auto C Flex CPAP 13CM H20 and in the absence of it he would go to long term complications. This diagnosis and the recommendation of the doctor has not been controverted by the Ops. The sleeping disorder is not a disease as contended by the 1st OP cannot be believed. What we should bear in mind the diagnosis and opinion of the doctor who treated the complainant and opined treating the complainant with CPAP is a must failing which it leads to long term complications which cannot be termed as not a disease. That disease is not found in the exclusion of the policy. The counsel representing the complainant by relying upon a decision of Consumer Disputes Redressal forum, Delhi and a decision of this forum in complaint NO:1473/08 dated 10-12-2008 has stated that the forums referred to above allowed the complaints and directed the insurance companies to reimburse the expenditure incurred for purchase of pace maker, cost of organs etc. Considering the above facts, purchase of CPAP by the complainant and there being no exclusion for reimbursement of expenditure for the ailment like this cannot get away from the liability to reimburse the complainant. Therefore repudiation of the claim of the complainant amounts to deficiency and we thus answer point NO: 1 in the affirmative and pass the following order. <br /> <br /> O R D E R<br /> <br /> Complaint is allowed. OP 1 and 2 are held jointly and severally liable to reimburse Rs.62,000/- + Rs.4000/- + Rs.180/- to the complainant within 50 days from the date of this order with interest @ of 9% per annum from the date of the claim of the complainant till the date of payment. <br /> <br /> Ops shall also pay cost of Rs.5000/- to the complainant. <br /> <br />