(Passed this on 22^th January,  2018)

Shri. S.P. Muley, President –

1.      This is a complaint regarding repudiation of mediclaim policy by the Opposite Parties.

2.      The complainant had purchased a medi claim policy in the year 2010-11 from the O.P.1 for a sum assured Rs. 3,50,000/-. A cover note was supplied. The policy was valid from 20/8/2010 to 19/8/2011. During subsistence of the policy the complainant was required to undergo medical treatment at Raheja Hospital, Mumbai. As per advise CT Scan of her abdomen and pelvis was done on 6/1/2011. Thereafter she consulted Oncologist Dr. Advani on 7/1/2011 and 8/1/2011. the doctor prescribed her some medicines and kept her on oral chemotherapy. Further treatment was taken at Nagpur. As she was covered under the medi claim policy, the O.P.1 was intimated about her treatment and expenses incurred by her. A claim for Rs. 93,550/- was then submitted with necessary documents to the O.P.1 on 7/2/2011. she thereafter submitted original documents to the O.P.2 on the instruction of the O.P.1. However, instead of settling her claim, the O.P.2 issued her a communication dated 4/3/2011 informing that the claim was repudiated on the false ground that she was not hospitalised. Alleging this as unfair trade practise and deficiency in service, she has claimed expenses Rs. 93,550/- with 18% interest along with compensation and cost.

3.      The O.P.1 filed reply and admitted the medi claim policy of the complainant. Denying that only cover note was supplied, it is stated the terms and conditions of the policy were also supplied to her. It is denied she is entitle to get actual expenses of her treatment as such expenses were not covered under the policy. Since she was not required to be hospitalised and all bills pertain to her medical investigations and consultation charges as an outdoor patient, she is not entitled to get reimbursement. The repudiation was intimated on 4/3/2011 and hence the complaint filed on 4/3/2013 is barred by limitation. Denying deficiency in service or unfair trade practise, it is submitted to dismiss the complaint.

4.      The O.P.2 despite service of notice failed to appear. Hence the matter proceeded ex-parte against it.

5.      We have heard Ld counsel for the O.P.1. None appeared for the complainant. The matter was  pending for oral submission since November 2016, we heard the submissions of the counsel for the O.P.1 and closed the case for judgment. Upon considering the submission and documents we record our findings for the reasons given below.

FINDINGS  AND  REASONS

6.      It is not disputed that the complainant had taken medical treatment and consulted an Oncologist. From her averments in the complaint and documents it can be said that she was not required to be hositalised. Thus she was treated as an outdoor patient at Mumbai hospital and in Nagpur as well. The mediclaim was repudiated on this sole ground that expenses incurred on treatment as outdoor patient is not covered under the policy.

7.      As said earlier, she has not produced any document showing her hospitalisation at any point of time. This can be seen from the letter of the O.P.2. It is clearly mentioned that she was not hospitalised but treated on OPD basis. Even from the certificate given by Raheja Hospital, Mumbai she was advised to take treatment at home in Nagpur under assistance of  local doctor. Thus there was no need for her to get her admitted in the hospital for treatment. No doubt, she did undergo CT Scan and took some treatment, but all those were taken as outdoor patient.

8.      If the terms and conditions of the mediclaim policy are perused it is manifestly clear that the policy reimburses the payment of Hospitalisation expenses only for illness/ diseases or injury sustained by the insured person. In view of this fact, repudiation of her claim cannot be faulted with. The O.P.1 was right in repudiating the claim.

9.      In view of our above finding, it becomes redundant to discuss on other aspect of the case. Nevertheless, it may be said that whatever bills filed by the complainant do not show she had made payment thereof. These are mere bills and no acknowledgment of receipt of payment can be found on any bills. There are only two receipts of Rs. 1000/- and Rs. 500/- received as consultation fees. This itself shows she was not an indoor patient. It is thus not necessary to delve much upon the bills.

10.    In the result, for reasons stated above the complaint is liable to be dismissed. We therefore pass the following order.

ORDER

1. The complaint is dismissed with no order as to cost.
2. Copy of judgment/ order be given to both the parties, free of cost.