Order-19.
Date-27/05/2015.
Complainant Sri Amitava Mitra by filing this complaint has submitted that complainant to cover up his health, purchased a Medicalim Insurance Policy (Individual) bearing Policy No.100900/48/12/8500005701 from the op for the period from 2013-2014 by paying annual premium of Rs. 14,224/- and as such policy was purchased on 22.03.2010 and it was continued year to year and renewed the same in accordance with the terms and conditions.
Since complainant was sufferings enormously from the said disease that is Sleep Apnea Syndrome i.e. loud snoring during sleep and he was advised to take medical assistance and as such he was diagnosed for the said disease on 23.10.2013 by Dr. Sumit Sengupta at AMRI Hospital who advised to undergo Sleep Test for probable Sleep Apnea and said sleep test was conducted by AMRI Hospital on 22.11.2013 at 21:29 hours and was discharged on 23.11.2013 at about 7:00 hours where he was treated by the said doctor and all the relevant documents, the medical reports, prescriptions, discharge certificate etc. were sent along with report of the doctor and complainant was asked to use C-PAP Machine on a regular basis and after said treatment and discharged by the Hospital, complainant raised the claim for reimbursement of the expenses so incurred by him in lieu of his treatment of the said disease vide letter dated 14.01.2014.
Complainant was issued discharge certificate as Day-Care Treatment on 15.02.2014 by the concerned Hospital and the same was submitted with the op – the insurance company on 18.02.2014. But vide a letter dated 25.03.2014 issued by the op no.2 addressed to the complainant refuted the claim on the ground that the said disease was not listed under Day-Care Procedure and so there was no hospitalization of the treatment and the claim is inadmissible under Clause 2.6 of individual mediclaim policy.
In reply complainant by sending a letter on 07.04.2014 challenged the repudiation dated 25.03.2014 and further submitted that the repudiation is completely illegal and also prayed for redressal.
On the other hand op nos. 1 & 2 by filing written statement submitted that as per Exclusion Clause 2.6, the present treatment of the complainant does not fall under the listed of Day-Care Procedure under Exclusion Clause 2.6. Further it is submitted that complainant has filed claim – one for OPD treatment for less than 24 hrs and the other for price of C-PAP machine and complainant lodged his total claim for Rs. 59,500/- out of which the cost price of C-PAP Machine is Rs. 50,000/- and rest is the cost of his OPD treatment at AMRI. Now the first part of the claim is OPD treatment for Rs. 9,500/- which was repudiated under exclusion clause 2.6 since the disease does not fall within the listed disease under Day-Care treatment and the 2nd part of treatment for cost of C-PAP Machine for Rs. 50,000/- is repudiated under clause 4.16 of the Exclusion Clause attached with the policy. So, there is no ambiguity or unclearness in repudiating the claim in op’s mind is a purported story and fact remains that there was no laches or deficiency on the part of the op and further fact is that for the wrongful gain out of the insurance contract, this complaint is filed as there is no deficiency or negligent or unfair trade practice on the part of the op for which the present complaint should be dismissed.
But op no.3 did not file any written objection to contest this case.
Decision with reasons
On careful study of the complaint and written version and also considering the argument as advanced by the Ld. Lawyer of the op and also including Clause 2.6 and discharge summary, it is clear that the present procedure of test was done as in patient department, but for some period not exceeding 24 hours and the test was done for Sleep Apnea Syndrome under Day-Care Procedure. But the said Sleep Apnea Syndrome is not received under the Day-Care Procedure as noted Clause 2.6 of the Policy and considering that fact it is clear that there is no hospitalization for the treatment and the claim is inadmissible no doubt under Clause 2.6. But regarding purchase of C-PAP machine it is to be mentioned that as per Clause 4.16 surgery for correction of eye sight cause spectacles contact lens hearing aids etc. are within the Exclusion Clause as per terms and conditions of the policy and fact remains that C-PAP Machine is nothing but one type of hearing aids and as per contract terms and conditions of the policy, the complainant is not entitled to get any reimbursement or payment in respect of purchasing C-PAP Machine. So, apparently op has pointed out the vital rules, regulations and terms and conditions of policy that is Clause 2.6 and 4.16, both are Exclusion Clause and in respect of obstructive treatment of Sleep Apnea Syndrome no treatment cost shall be paid by the op.
So, apparently the repudiation as made by the op is found as per terms and conditions of the policy, no illegality or proper regulations on the part of the op is proved. But anyhow this complaint was filed for disbursement of the amount. No doubt in respect of C-PAP Machine, no reimbursement can be made as per terms and conditions of the policy. No doubt complainant spent Rs. 9,500/- for treatment of Sleep Aponea Syndrome. But it is not policy disbursement in view of the fact that there is Exclusion Clause 2.6 and in the said clause, it is noted for what type of treatment in Day-Care Procedure, the reimbursement may be made.
But after proper scrutiny of the claim, the said treatment of Sleep Apnea Syndrome is not entitled and complainant is not entitled to get any mediclaim in support of that part for which we are convinced to hold that there is no merit in this complaint and the repudiation is made by the op which is legal and at the same time complainant is bound by the terms and conditions of the policy and there is no question of giving any relief by applying law of equity, in the present case in view of the standing judgement of National Commission go beyond the terms and conditions of the policy and parties shall be strictly governed by the policy conditions and no exception or relaxation can be made on the ground of equity [referred ruling in 2013 (4) CPR 165 NC].
So, in the result this complaint fails.
Hence, it is
ORDEDRED
That the complaint be and the same is dismissed on contest against all the ops but without any cost.
