Order-10.

Date-13/10/2015.

This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that complainant purchased individual health insurance policy from OP1 on payment of premium of Rs.1,749/- including service tax being Policy No.311700/48/2015/2563 for the period from 10-07-2014 to 09-07-2015 having sum insured of Rs.1 lakh.

          During the subsistence of the policy the complainant suffered abdominal pain and serious abdominal ailment for which he was attended to OPD Gastroenterology, Rabindranath Tagore International Institute of Cardiac Science to Dr. S. Pal on 05-11-2014 and as per doctor’s advice he was admitted to that hospital for treatment on 06-11-2014 and was discharged by the doctor on 07-11-2014 at 12.00 noon and at the time of discharge complainant produced the cashless card to the hospital authority issued by the OPs 1 and 2 for availing cashless facility but OP2 denied the claim by issuing a denial letter dated 07-11-2014.  Thereafter, after discharge the complainant filed a claim for full payment of the bill of hospital as cashless facility was refused but OP remained silent regarding the payment of Rs.15,046/- submitted by the complainant on 12-11-2014 to OP2.  Then complainant visited the office of the OP2 on several occasions but they did not make any comment and did not dispose of the same for which complainant has filed this complaint for refund of Rs.15,046/-, the cost of the bill incurred by the complainant as treatment of the complainant in the hospital and other relief.

          On the other hand, OP by filing written statement submitted that patient was diagnosed for evaluation of diagnostic matters but there is no active line of treatment so the purpose of hospitalization is not determined and, in fact, as per hospital progress note the patient was advised for observation plan and the patient is known case of HTN & Hypothyroidism which is a waiting period of two years etc. 

          Further it is submitted that as per Clause 4.2 the expenses on the treatment of following ailment/disease/surgeries for the specified periods are not payable if contacted and/or manifested during the currency of the policy and if the deceased are preexisting the Exclusion Clause 4.1 the pre-existing shall be applicable for such case, moreover hypertension was for 2 years and considering the Clause 4.8 the claim was repudiated and it was intimated to the complainant on 13-03-2015 and complainant received it.  So, there was no negligence, deficiency on the part of the OP.

          It is further submitted that in respect of no active line of any treatment or for any other case no insured can get mediclaim policy and in this regard National Commission by its judgment passed in CPR 2013 (4) Page 165 observed the policy that policy condition shall be followed by the Forum and no examination or relaxation can be made on the ground of equity for violating the terms and condition of the policy complainant is entitled to get any relief.  So, the repudiation is justified and for which the complainant is not entitled to get any relief.

Decision with Reasons

On comparative study of the complaint and the written version and also considering the daily hospital and physical examination of the Rabindranath Tagore Institute and Research Hospital it is found that at hospital only different tests like biochemical test, x-ray was done and it was found that there was renal cortical cyst, hiatus hernia and as per medical report it is found that only for assessment of the said reports and for observation she was admitted.  But no treatment was done only on release medication was advised and clinical discharge summary also supports that.  So, considering that fact it is clear that no treatment was given by the Rabindranath Tagore Hospital only some tests were done and it was detected that there was some problem that is hiatus hernia, renal cordial cyst and suffering from gastritis for one year and there is no active line of treatment.  So, apparently it is found that hospitalization was not necessary, only tests and clinical tests etc. and x-ray can be done as OPD patient and as per Clause 4.8 expenses incurred for hospital or diagnostic purpose but not followed by active treatment for ailment during the hospital period cannot be granted and as per Exclusion Clause 4.8 complainant is not entitled to get it and no doubt the matter was reported by the OP vide their letter dated 13-01-2015 but that has been suppressed by the complainant.  Fact remains complainant is covered by mediclaim policy no doubt.  But complainant is guided by the terms and condition of the policy and the testing can be done as OPD patient but that has not been done and practically it is not done in view of the fact.  If it is done without admission in hospital or nursing home in that case the patient shall not have to get the benefit for the cost of the x-ray etc.  So, all the private nursing home are obliging the patient for admitting one day and during that period different tests have been made and that is the common practice also of the policy holders and when as per policy condition 4.8 when active treatment is not there then even if patient is admitted by doctor and only tests are being done and no active treatment is given in that case as per Clause 4.8 patient is not entitled to get any benefit of mediclaim and in this regard no doubt complainant is guided by the terms and condition of the policy and so the repudiation as made by the OP is found justified when insurance company took decision after application of mind.  So, there is no negligence and, deficiency on the part of the OP.  In the light of the above observation we are convinced to hold that the present complainant is not entitled to get any benefit as claim when repudiation is justified as per terms and condition of the policy

In the result, the case fails.

Hence,

Ordered

That the case be and the same is dismissed on contest but without any cost against the OPs.