Order No. 23 dt. 26/12/2016
The case of the complainant in brief is that the complainant was subscriber of a mediclaim policy with hospitalization benefit in the year 2010. After the expiry of the said policy the complainant subscribed to a fresh hospitalization benefit policy bearing policy no.154300/48/11/8500005890 issued by o.p. no.1. During the subsistence of the said policy the complainant was admitted in an ayurvedic eye hospital. After discharge from the hospital the complainant submitted her claim and the claim was repudiated on the ground that the treatment administered to the complainant excluded from the policy in terms of clause 4.24 clause of the mediclaim policy. It was stated that the treatment rendered to the complainant by the said hospital was not excluded from the said policy. On the basis of the said fact the complainant claimed the amount paid for her treatment to the tune of Rs.64,129/-, Rs.1 lakh for damages and Rs.20,000/- for litigation cost .
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the insurance policy was circumscribed by its terms and conditions and the same are binding upon the parties. At the very inception of accepting the policy the complainant was well aware in respect of the scope and ambit of the said policy and hence such grievance as raised by the complainant at the later stage in respect of the exclusion clause of the said policy is not sustainable in the eye of law. The claim made by the complainant was referred to the TPA and an explanation was sought from TPA regarding the claim of the complainant. In response to the letter TPA informed the o.ps. that all the procedures comes under message / steam bath / surodhara and alike ayurvedic treatment except virecharan and all the procedure done are OPD procedure and takes approximately 2-3 hours and does not require hospitalization except virecharan. Since the claim of the complainant is excluded from the policy as laid down in clause 4.24, therefore the complainant will not be entitled to get any claim as prayed for.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy at the relevant point of time.
- Whether the treatment rendered to the complainant false within the ambit of the policy.
- Whether there was any deficiency in service on the part of o.ps.
- Whether the complainant will be entitled to get any 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 valid policy at the relevant point of time for the treatment of the complainant she was admitted in the Sridhareeyam an ayurvedic eye hospital for the treatment of defective in both eyes. After her treatment the complainant claimed the reimbursement of the medical expenses to the tune of Rs.64,129/-, but the same was denied without any cogent reason whatsoever. The complainant while found that her claim was repudiated she had to file the case before this Forum to ventilated her grievance and on that basis the complainant claimed the amount for her medical expenses as well as compensation and litigation cost.
Ld. lawyer for the o.ps. argued that the policy is circumscribed by its terms and conditions and the same are binding upon the parties. The terms and conditions of the respective policy are approved by IRDA. After receiving the copy of complaint o.ps. called for a clarification from TPA which was replied by TPA mentioning therein that all the procedure comes under message / steam bath / surodhara and alike ayurvedic treatment except virecharan and all the procedure done are OPD procedure and takes approximately 2-3 hours and does not require hospitalization except virecharan. Since the complainant could not prove that she was treated for virecharan therefore she was not required to take hospitalization and if she was not hospitalized she will not be entitled to get the claim as made by her. Apart from the said fact the exclusion as laid down in the policy envisaged in 4.24 clarifies that the treatment given to the insured will not be covered under the policy. In view of the said fact o.ps. prayed for dismissal of the case.
Considering the submissions of the respective parties no one has disputed that the complainant was not covered with the policy at the relevant point of time. On perusal of the policy it appears that as per exclusion clause as laid down in the terms and conditions of the said policy in clause 4.24 it was stated that message / steam bath / surodhara and alike ayurvedic treatment. Here in this case the complainant failed to prove that she was rendered treatment of viracharan which requires the hospitalization. The treatment rendered to the complainant was an OPD treatment and it required 2-3 hours duration. Therefore we hold that the TPA rightly observed that as per exclusion clause 4.24 of the terms and conditions of the policy the complainant will not be entitled to get the reimbursement of the claim as made by her. On perusal of the evidence on record and also the terms and conditions of the said policy which is approved by the IRDA we cannot import any explanation by altering the terms and conditions of the policy in order to give relief to the complainant. In view of the facts and circumstances of the case we hold that o.ps. did not commit any deficiency in service or unfair trade practice and as such, 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.215/2013 is dismissed on contest without cost against the o.ps.
Supply certified copy of this order to the parties free of cost.
