JUDGEMENT

          Complainant by filing this complaint has prayed for releasing of Rs. 48,803/- as medi-claim for his treatment at Apollo Gleneagles Hospital for the period from 24.08.2013 to 28.08.2013 as he is the holder of Mediclaim Policy under the op no.1 and that treatment was needed for palpitation, chest pain, weakness, sweating and snoring (+) disturbed sleep and after discharge from the Hospital complainant submitted mediclaim form along with documents and medical expenditure etc for an amount of Rs.48,803/- and said hospital also sent a letter to the op no.2.  But op no.2 reported in the said letter that the proposed claim and facility of the complainant is not applicable and that matter was reported by the Hospital Authority to the complainant.

          But op repudiated the claim on the ground that the present claim is for the management of obstructive sleep apnea and metabolic syndrome as reflected from discharge certificate.  As per document submitted which reveals that no active treatment has been given and treated only with oral medicine.  Another point is that during hospitalization only for investigation and evaluation are done of which polysomnography C-PAP Titration and sleep study done.  The major medication on Tab PATIUM.  Since the above said reason are not payable as per clause 4.10 and 4.16 respectively of NIC policy condition but such sort of claim of complainant is completely baseless and without any foundation and fact remains the total bill was paid for Rs. 51,293/- and complainant has claimed only Rs. 48,803/- and there was no ground for repudiation for which for negligent manner of service and for adopting unfair trade practice this complaint is filed.

          On the other hand op by filing written statement submitted that after considering the material document and also the observation of the diagnosis ‘ Obstructive sleep apnoea secondary to obesity’ and so sleep apnoea being the secondary to obesity attract exclusion Clause 4.19 of the policy which clearly states ‘treatment for obesity or condition arising therefrom.  No claim can be entertained and so the claim was rejected as per Clause 4.19 and the repudiation was made by the Insurance Company on good faith caused material collected pursuant to enquiries made is no deficiency in service on the part of the LIC and for which the present complaint should be dismissed.

                                                       Decision with reasons

          On in depth study of the complaint including written version and also the argument as advanced by the Ld. Lawyers of both the parties including the documents produced by the complainant, it is clear that complainant was admitted for a history of  Obstructive sleep apnoea secondary to obesity and that is the diagnosis of the doctor as per chart.  But in fact the conservative treatment was done for the period from 24.08.2013 to 28.08.2013 and fact remains only one tablet was used always by the doctor i.e. Tab PANTIUM and no other medicine was used.  But such a treatment can easily be done on conservative basis when on the very first date within 24 hours and all the investigations were completed.

          So, in view of the above fact and also considering the policy condition, it is clear that for conservative treatment at hospital complainant is not entitled to any treatment cost.  At the same time complainant’s policy was for sum assured of Rs.1,00,000/-.  So, as per policy condition, he is entitled to room rent @ 1% of the sum insured per day.  So, accordingly at best he is entitled to Rs. 1,000/- per day for room rent.  But room rent for 4 days was Rs. 8,800/- but complainant is entitled only Rs.4,000/-.  But pharmacy charges of Rs.5,503/- is not admissible as per policy condition and at the same time sterilization of general ward of Rs.336/- is also not admissible, though Rs. 1,160/- was charged, Rs. 600/- for medical records that also cannot be allowed and at the same time as per general rule for conservative treatment only medicines, doctor’s fees can be granted.

          So, considering the entire fact and also the Clause 4.19 of the Insurance Policy that rejection was to some extent justified.  But from the report it is clear that he has suffered from sleeplessness due to nasal obstructive and it was caused due to metabolic syndrome and it is also opined by the doctor and at the same time doctor has confirmed that therapy is nothing but to modification of life style, mechanical intervention etc.  But obesity is here and there, it is proved for which it was rejected.

          But considering all the above fact and circumstances and considering the payment of premium and further the present trend of checking up in the renowned private hospital to the patient has become a practice and practically he was hospitalized for checking up and no particular treatment was started and treatment was given only and he was advised for modification of lifestyle and mechanical intervention apart from just giving was done.  So, no doubt the repudiation as made by the op was justified.  So, under any circumstances we cannot go beyond the rules and regulations and terms and conditions of the policy.  It is to be mentioned that in this regard that complainant’s admission to hospital without any active terms if any patient is released and in that case such a patient can get benefit of the mediclaim policy and this matter shall be kept in the mind of the patient before checking his whole body by any private nursing home etc only to holding a mediclaim policy and this practice should be discontinued or some other policies are here and there where everything shall be covered in this regard including checking etc and for which higher premium shall be paid by the patient or the complainant.

          At the same time after consulting the materials on record, it is found that complainant was not admitted for any serious disease where admission was necessity and considering the above fact and the clause as mentioned in the policy, it is clear that repudiation was justified and it was really made after consulting all the medical papers as produced by the complainant.

          In the result this complaint fails when deficiency and negligence or any sort of immoral activities has not been done by the op and that has not been proved by the complainant and for which the complaint fails.

          Hence, it is

                                                             ORDERED

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

          Complainant shall have to pay the cost of the op Insurance Company.