Order No. 24 dt. 23/05/2017
The case of the complainant in brief is that the complainant has the mediclaim policy under o.p. no.1. The complainant for his treatment took admission on 21.6.09 at AMRI Hospital, Salt Lake, Kolkata and she was discharged on 23.6.09. After release from the hospital she submitted a medical bill of Rs.34,104 for reimbursement. The complainant stated that the said bill was not considered by o.ps. thought two years have lapsed and as such for deficiency in service the complainant filed this case praying for direction upon the o.p. insurance company for payment of the said amount as well as compensation of Rs.20,000/- and interest.
The o.p. no.1 contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that it is the settled law that insurance company is under obligation to settle the claim within the reasonable time i.e. within 2-3 months and o.ps. vehemently denied that the claim of the complainant kept pending for more than two years. It was specifically stated that the complainant is the mediclaim policy holder under o.p. no.1 and the date of commencement of risk continued from 23.5.09 to 22.5.10. The o.p. no.1 in order to settle the claim of the complainant asked the complainant to submit the original documents for settlement / reimbursement of the medical bill as per the terms and conditions of the policy. The o.p. no.1 with an intention to settle the claim of the complainant placed the available relevant documents along with the claim application of the complainant before o.p. no.2 to investigate and settle the claim of the complainant as per the rules and terms of the insurance policy. The o.p. no.2 after completion of investigation gave an opinion against the claim of the complainant and the claim was repudiated as per exclusion clause no.4.10 as per clause no.10 of the revised individual mediclaim policy. The complainant was as hospitalized at AMRI Hospital on 21.6.09 for Hypothyroidism with UTI and was discharged on 23.6.09. The doctor of TPA scrutinized the medical documents and found that the hospitalization was primarily for investigation purpose and for diagnostic purpose and not followed by active line of treatment. Therefore, the claim was repudiated as per exclusion no.4.10 of the revised individual mediclaim policy. The repudiation made by insurance company was done in accordance with law and no illegality was committed by insurance company, therefore o.p. no.1 prayed for dismissal of the claim.
In spite of receipt of notice the o.p. no.2 did not contest the case by filing w/v and as such, the case has proceeded ex parte against the o.p. no.2.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant was insured with o.p. insurance company.
- Was the repudiation made by o.p. insurance company violated the terms and conditions of the policy.
- Whether there was any deficiency in service on the part of o.ps.
- 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 was the mediclaim policy holder of o.ps. and she was admitted to AMRI Hospital and after her release while she submitted the bill for reimbursement the same was kept pending for two years for which the complainant had to file this case praying for direction upon the o.ps. for release of the fund as well as compensation.
Ld. lawyer for the o.p. no.1. argued that the complainant was insured with the o.p. insurance company. The plea taken by the complainant that the insurance company did not take any action was not correct, since it is the duty of the insurance company to settle the claim of the insured within 2-3 months from the date of submission of all the documents in respect of their claim. In this case, initially the complainant failed to produce the original documents, subsequently with the filing of the documents the same was sent to TPA and the doctor attached to TPA and after scrutinizing the medical papers o.p. no.2 came to the conclusion that the complainant took admission in the said hospital for investigation purpose and there was no follow up treatment and/or any medicines was prescribed by the doctor in respect of the admission of the said patient in the said hospital. Therefore, as per exclusion clause of 4.10 the claim of the complainant was repudiated and there is no deficiency in service on the part of insurance company and therefore o.p. no.1 prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant had was taken admission at AMRI Hospital and after release from the hospital she submitted medical bills to o.p. no.1. It is also an admitted fact that o.p. no.1 after receiving the medical bills forwarded those documents to TPA to investigate and settle the claim of the complainant as per rules and terms of the insurance policy. The o.p. no.2 after investigation and examining the papers came to conclusion with an opinion against the complainant and repudiated the claim as per exclusion clause no.4.10 and as per clause no.10 of the revised individual claim of the policy. The materials on record established the fact that the complainant was admitted at AMRI Hospital on 21.6.09 for Hypothyroidism and UTI and was discharged on 23.6.09. It is also an admitted fact from the materials on record that the doctor of TPA scrutinized the medical documents and found that the hospitalization was primarily for investigation purpose and/or for diagnostic purpose and not followed by active line of treatment or in words the complainant underwent oral line of treatment and hospitalization was for investigation purpose. In view of the said materials on record we find that as per the terms and conditions of the policy the claim of the complainant was not accepted and thereby the repudiation was made by o.ps. and there was no deficiency in service on the part of o.ps. 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.538/2012 is dismissed on contest against the o.p. no.1 and dismissed ex parte against the o.p. no.2 without cost. Supply certified copy of this order to the parties free of cost.
