JUDGEMENT

          Complainant’s plain case is that he purchased one Mediclaim Insurance Policy for himself and her mother and for Smt Bani Mitra being Policy No.104200/48/10/85000009987 which was valid from midnight of January 20, 2011 to midnight of January 19, 2012 and policy documents was issued and it was continuous policy for several years since 20.01.2005.

          During validity of the said policy, Bani Mitra aged about 70 years had been suffered a severe chest pain along with palpitation for which she was admitted Apollo Gleneagles Hospital where she was initially taken to the out patient department for checking and diagnosed with palpitation and pre-syncopal attack by the attending doctor of that hospital Dr. Prakash Chandra Mondal and the said attending doctor after considering the age of the patient, her deteriorating condition and other symptoms advised for immediate admission in the hospital for treatment and she was admitted in that hospital from 02.02.2011 to 04.02.201 and thereafter she was released in a Haemodynamically stable condition and it was found that she was suffering from Diabetes Mellitus Type-II, Hyperuricaemia and Atypical Chest Pain and after discharge claim was submitted to the Insurance Company and thereafter TPA sent a letter on 12.05.2011 for filing first consultation note and all prescriptions related to Diabetes Mellitus and Hyperuricaemia.  When the complainant visited the office of TPA on 24.05.2011 and resolved the matter and again received a communication on 14.07.2011 from the Divisional Manager of op stating that all investigation reports show that this treatment would be done on OPD basis and OPD treatment is excluded under point No. 4.10 of the Mediclaim Policy and the said letter of the op on 14.07.2011 also mentioned that Insurance Company is absolving themselves from any further liabilities arising out of the said claim.  So, the repudiation of the claim was made on 14.07.2011.

          After complainant approached the attending physician Dr. Prakash Chandra Mondal for clarifying the reason for objections raised in the claim and for closing the claim and whether the treatment could have done on OPD basis and the concerned doctor categorically clarified in certificate on 25.07.2011 that the patient was suffering from palpitation and pre-syncope with which the patient reported at OPD and further clarified that Pre-syncope in a patient aged about 65 years needs urgent indoor evaluation and the copy of the clarification on 25.07.2011 is also filed.

          Further it is submitted that the patient was under continuous medical treatment of Dr. P.C. Mondal and visited and consulted him at the hospital on several occasions after her release and on some such occasions on 24.02.2011 and 25.07.2011 and complainant wrote to the Divisional Manager of the op on 27.07.2011 enclosing the Certificate of the doctor clarifying the need for urgent admission of the patient and about OPD treatment etc. but op did not consider and for which for deficiency of service, complainant has filed this case only for release of Rs.23,681.82 paisa which was spent for the purpose of treatment of Bani Mitra and for redressal.

          On the other hand, the Insurance Company by filing written version submitted that no doubt complainant is a Mediclaim Policy holder and it was valid and fact remains that he submitted a bill, TPA no doubt sent letter on 12.05.2011 to the complainant for her mother’s treatment with a request to submit first consultation note and all prescriptions related to Diabetes Mellitus and Hyperuricaemia and complainant replied by a letter dated 24.05.2011 but failed to produce of those documents.  Thereafter TPA again sent letter on 08.06.2011and complainant on perusal of the documents, it is found that payment for investigation purpose and no active line of treatment found, and only oral medication is given.  Hence TPA regrets their inability to admit this liability and present claim merits repudiation as per policy exclusion Clause 4.10.

          Moreover after filing of all the papers, it was found that all investigation reports showing that this treatment would be done as OPD basis and OPD treatment is excluded under Clause 4.10 and expenses incurred primarily for evaluation/diagnostic purposes not followed by active treatment during hospitalization.  So, it is not entertain able as per clause and further as per terms and conditions of the policy, the same was repudiated.

                                                    Decision with reasons

          Fact remains in this case argument was heard at lengthy from the complainant’s Ld. Lawyer who tried to convince that op repudiated the claim for disbursement of Rs.23,681.82 paisa and in respect of treatment of Bani Mitra, the insured without any reason when the discharge summary was issued by Dr. Prakash Chandra Mondal the treating doctor and as per his advice Bani Mitra was admitted and she was aged about 69 years on the date of her admission on 02.02.2011 and no doubt after treatment made by the Dr. Mondal she was discharged on 04.02.2011 and during that period of stay and treatment cost the bill claim was submitted.  But repudiation was made by the op is completely illegal in view of the fact that Bani Mitra was not admitted casually.  But she was feeling palpitation and pre-syncopal attack and for which treatment was done at hospital to improve her condition and doctor after release advised for further medication.  But ops did not consider the discharge summary but asked for further clarification and that mater was clarified by Dr. Mondal on 25.07.2011 and that was submitted to op but op did not consider and did not settle the claim and repudiated the same which is completely illegal.

          But on the other hand ops’ Ld. Lawyer submitted in fact in the discharge summary, there is no question of treatment, but only diagnosis was made and she was suffering from Diabetes Mellitus, Hyperuricaemia and Atypical Chest pain and in that case hospitalization is nothing but relevant examinations that is tests etc. but in the discharge summary there is no treatment regarding any treatment and actually after testing she was released with the advice for taking some prospective test so that that the Diabetes Mellitus and Hyperuricaemia may be controlled and after considering discharge summary and also the Clause-4.10 of the contract, TPA and the op Insurance Company refused the same because expenses incurred primarily for evaluation or diagnosis purpose not followed by active treatment during hospitalization is not covered by the policy.

          Considering the argument as advanced by the Ld. Lawyers of both the parties and also considering the discharge summary, it is clear that practically even two days only stay primarily for evaluation/diagnostic purposes she was admitted and said diagnostic purposes was completed and it was detected that the lady has been suffering from Diabetes Mellitus and Hyperuricaemia and also Blood Sugar etc.  so, at the time of discharge, some protective drugs were advised to take the patient so that the Hypertension and including the Blood Sugar may be controlled.

          But fact remains that she was aged about 69 years and no doubt considering the policy conditions and the discharge summary, we find that there was no negligence on the part of the op for repudiation and in this regard both the parties are guided by the conditions of the policy and in this regard it is settled principal of law that Forum cannot go beyond the contract and Forum cannot hire new interpretation of the conditions   and clause of the policy, rule of law is that both the parties shall be strictly governed by the policy conditions and there is no scope on the part of the parties to interpret otherwise and in this regard we are guided by the ruling reported in 2013 (4) CPR 165 (NC) and in view of the above fact and the principal of law as laid down and also considering the entire fact, we are convinced to hold that there was no laches on the part of the op for repudiation.

          But in this case one matter should be considered because a lady aged about 69 years was admitted with Hypertension and other problems, then invariably when she was placed before the doctor of Apollo Gleneagles Hospital, they found that without diagnosis, no medicines should be give and it would be harmful, in view of the fact the age was factor.  After diagnosis it was found that she was suffering from Hypertension and Blood Sugar.  So, during treatment hours such medicines were advised but no prescription was attached with the said discharge summary schedule actually what medicines were given.  But unfortunate fact is that the hospital authority did not submit the treatment sheet to the TPA or the op not even same are submitted by the complainant before the Forum to ascertain what the medicines were used.

          Considering the certificate of the treating doctor on 25.07.2011, we find that doctor was justified because in such condition the conservative treatment at home cannot be possible because in such a condition many patient dies and without proper investigation medicines cannot be advised.  So, in this regard the doctor is justified and fact remains to save the lady from such a situation she was advised for admission and practically she took all such steps and held all investigations and after that evaluated that the lady has been suffering from Diabetes Mellitus and Hyperuricaemia.  So, medicines were advised to take the preventive methods.  So, in this regard the complainant and Bani Mitra had no fault because a patient is guided by the advised of doctor because doctor is the best person to decide whether patient would be admitted or not because admission was not made as per will of the complainant or Bani Mitra and particularly considering that aspect we are convinced to hold that admission was necessary for which she was admitted, treatment was done after thorough investigation and it was detected that she was suffering from Diabetes Mellitus and Hyperuricaemia and other diseases.  Thereafter medicines were advised.

          But peculiar factor is that bills were submitted by Apollo Gleneagles Hospital and particularly we have gathered that pre-filled syringe for a cost of Rs.506.01 paisa was charged but reasons for using such pre-filled syringe is not supported by the doctor’s prescription.  Moreover no medical bills or vouchers along with batch number, MRP are not filed and that is the practice of the private hospital to prepare in such a manner the bill and in some cases this Forum has searched out that medicines bills are higher than that of the total MRP and that practice is continued by the private hospital in so many cases.

          So, anything submission of the bills by the hospital authority in respect of purchase of those articles we find that in such a manner the bills cannot be considered by the Insurance Company.  But even then considering all aspects and also considering the age of the lady and her situation at the relevant time for admission a sum of Rs.25,000/- is granted for release by the op and practically this award is made by this Forum after considering the entire context of treatment and admission of the lady.  Though we are sure that as per conditions they are not entitled to.  But sometimes doctors are not in a position to determine the actual cause of such sort of suffering chest pain or palpitation etc. of a patient aged about 69 years and to that effect doctor was justified what we have gathered for which we have allowed the above amount considering the whole aspect and probably this matter was not viewed with such social and moral approach by the ops and for which the said claim was completely repudiated only applying strict rule of law as enumerated by the terms and conditions of the policy.  But in this regard we are directing the Insurance Company to be more social and moral for future so that such sort of case may not be repudiated only relying upon the strict rule of laws because sometimes conditions as imposed in the policy documents are not sufficient in view of the ailment of the patient.  So, ailment of the patient and cause of admission of the patient in the hospital or nursing home must be looked into and construed with such moral views otherwise for instance of such painful and critical condition of the policy the Mediclaim Policy holders shall be deprived of to get justice.  When Insurance policy is nothing but an act of welfare state and social welfare should be looked into by the Insurance Company in future any exceptional case but not always we are telling.

          In the result, complaint succeeds.

          Hence, it is

                                                         ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs.2,000/- against the op.

          Op Insurance Company is directed to release the sum of Rs.25,000/- in favour of Bani Mitra the insured and also the cost as awarded i.e. total Rs.27,000/- within one month from the date of this order treating that claim is finally settled by this Forum on contest.

          Op Insurance Company is directed to comply the order very strictly failing which for non-compliance of this order within the stipulated period, failing which penal action shall be taken and further the op Insurance Company shall be imposed penalty @ Rs.100/- per day till full satisfaction of the decree.