JUDGEMENT

          Complainant by filing this complaint has prayed for paying appropriate compensation for disbursement of claim amount of Rs.79,490/- as Mediclaim and also compensation of Rs.20,000/- on the ground that complainant is a bona fide holder of Mediclaim Policy with the op no.1 since 1992 to 2000.  When it was valid due to illness he was consulted with Dr. S.M. Lakhotia who advised for hospitalization.  But complainant did not follow the medicines prescribed and rushed to Christian Medical College and Hospital (CMC) at Vellore on prior appointment on 27.11.2011 and CMC Authority undertook treatment without hospitalization but carried out OPD consultations, x-rays and prescribed physiotherapy considering the condition of the complainant having an implanted pacemaker preventing magnetic check-ups/or tests like M.R.I. and considering the health status of the complainant they also conduct MYLO C.T. Scan with adequate guards and upon discharge on prescribed treatment and diagnosis thereon, CMC authorities declined to take the risk of MYLO C.T. Scan in view of transplanted pacemaker.  Thereafter no significant improvement was found, so he rushed to Appolo Speciality Hospital in Chennai on 03.12.2011 and concerned Neurosurgery Department underwent MYLO C.T. Scan tests but for effective treatment again he was hospitalized Appolo Speciality Hospital at Chennai on 03.12.2011 and that was duly transmitted and informed to the op and the complainant upon discharge after treatment from the said Appolo Hospital on 08.12.2011continued conservative treatment and complainant thereafter lodged claim on 02.01.2012 in respect of the existing valid policy No. 154300/48/10/8500005570 which was valid till 23.02.2012 with the op no.1 along with bills of Rs.67,935/-, supplementary bill of Rs.11,755/- but the complainant’s claim was turned down by the op when considering the same and in such a way op has harassed the complainant and due to negligent manner and deficient of service, the complaint was filed for redressal.

          On the contrary the op by filing written version has submitted that complainant took a Health Insurance Policy from the op no doubt, and during the validity period of the second year of policy the case made out by the complainant that he had sudden severe pain at left gluteal region for which he virtually lost his ability to work.  But such treatment of complainant is not true as because the doctor of the complainant himself in his prescription has clearly written that he is walking well after treatment.  Thereafter the complainant though went to CMC, Vellore but as he was not admitted there, following terms and condition of the policy of insurance, the op has no liability to pay any claim and compensation to the complainant.  Further, it is submitted that thereafter the complainant though admitted in Appolo Speciality Hospital in Chennai, but same has no connection with the alleged ailments alleged to have been suffered by the complainant and complainant was primarily admitted for investigation purpose only, therefore following the Clause 4.10 of the terms and conditions of the policy, the complainant is not entitled to any claim and compensation as prayed for.  It is further submitted that even if for the sake of argument it is assumed though not admitted that the present claim of the complainant is payable, in that case, the complainant is not entitled to any expenses incurred by him towards physiotherapy as the same is not covered by the terms and conditions of the concerned policy of insurance and therefore the op no.1 & 2 has no liability to pay any expenses incurred by the complainant towards the professional fees of such physiotherapist.  This op nos. 1 & 2 also submitted that the doctor of the complainant suggested that he has been cured, in spite of that complainant further continued in his physiotherapy without any further necessity and then there is no question of reimburse the expenses incurred by complainant for such unnecessary physiotherapy and further op denied all the allegations and prayed for dismissal of this case.

                                       Decision with reasons

          On in depth study of the complaint including the written version of the op and also Clause 3.11, it is found the minimum period of stay in the hospital or nursing home shall be 24 hours other than case mentioned in Clause 2.6 further from the discharge summary it is admitted that complainant has been suffering from Diabetes and Hypertension with such past history and also history of Cardiac Pacemaker placement in the month of Feb. 2007 and his age is about 67 years.  But he was discharged from the hospital on 08.12.2011 and he was admitted on 03.12.2011 and in the regard considering the discharge certificate, it is found that complainant at the time of purchasing the said policy did not declare that he had been existing heat problem and Cardiac pacemaker was placed in the month of February 2007 and he had his continuous pre-existing diseases of Diabetic Mellitus and Asthmatic Hypertension and Hemorrhoids and practically from the discharge certificate it is found that he was discharged on 08.12.2011 in stable condition  with advise to take such medicines.  But in the advice list, there is no instruction for taking further physiotherapy.  So, at best we may consider his treatment cost for the period from 03.12.2011 to 08.12.2011.  But if we consider the terms and conditions of the policy, we find that we are bonded in view of the fact that Mediclaim Policy is a contract and Forum cannot go beyond the terms and conditions of the contract under any circumstances.  But only to give some relief to the complainant when he is a senior citizen aged about 67 years, we have tried to go through the documents by which complainant cannot prove that he has claimed such amount.  But in this regard we have considered the document of the complainant wherefrom it is found that complainant has not produced any paper to show that he spent such an amount as claimed and no discharge bill of Appolo Speciality Hospital is produced.  But even then considering the entire fact and circumstances, we have gathered that as per terms and conditions of the policy, complainant is not entitled to get any relief from the op in view of the fact, complainant purchased the Mediclaim Policy suppressing his all pre-existing diseases and placement of pacemaker to protect his heart in the year of 2007 and for non-disclosure of all matter, it is found that he is not entitled to any such relief as per Mediclaim Policy.  But now he has spent some amount, but he has not produced those vital bills issued by the said Appolo Speciality Hospital at Chennai and he has claimed more than Rs.79,000/-.  But considering all the above fact and circumstances to give him a relief to settle the entire matter we are directing the op nos. 1 & 2 to pay a sum of Rs.40,000/- as final settlement of the rejected mediclaim within one month from the date of this order. 

Accordingly, the case is disposed of finally.

Hence, it is

                                         ORDERED

That the complaint be and the same is allowed on contest with cost of Rs.1,000/- against op nos. 1 & 2.

Op nos. 1 & 2 are hereby directed to pay a sum of Rs.40,000/- to the complainant within one month from the date of this order without any further delay and if op fails to comply the order, in that case for each day’s delay a sum of Rs.200/- per day shall be assessed till full satisfaction of the decree and if it is collected same shall be deposited to State Consumer Welfare Fund of this Forum by the op nos. 1 & 2 and even then if repeated disobeyance of the Forum’s order is found in that case op nos. 1 & 2 shall be prosecuted and even penal proceeding may be started.