Order-16.
Date-28/08/2015.
In this complaint Complainant Smt. Lovely Chakrabortyby filing this complaint has submitted that complainant purchased one Mediclaim Policy being No. 311500/48/2012/1263 for the period from 22.05.2012 to midnight 21.05.2013 with the op The Oriental Insurance Company Ltd. and this policy is Happy Family Policy for the benefit of his wife Lovely Chakraborty, the complainant and his son Rahul Chakraborty and for himself up to insured sum amounting to Rs. 3,00,000/-.
Complainant’s husband hired services from the op no.1 for consideration by entering a mediclaim policy for his family members and Lovely Chakraborty complainant.So the complainant, her husband and son are beneficiary to get service and accordingly complainant as wife of Arun Kumar Chakraborty is consumer under the op.
As per the mediclaim policy insurer promised to provide services in respect of any disease or bodily injury which was required advice of a doctor or surgeon and to incur reasonable and necessary hospitalization expenses for medical/surgical treatment at the any nursing home etc.Fact remains that complainant was compelled to visit Dr. Goutam Das on 03.10.2012 due to physical disorder i.e. ailment and was advised to do MRI and prescribed medicine which complainant took and this pre-hospitalisation medical expenses amounting to Rs. 5,809/- was incurred by the complainant within the period as per provision No. 3.6 of the said policy.
After that complainant was admitted as in patient on 10.10.2012 at Medica Super Speciality Hospital found the disease Fibromyalgia Cervical Vadiculopathy right sided due to PIVDC5-6 which was not pre-existing disease as per clause 4.1 of the said policy and for that reason complainant spent sum of Rs. 63,755/- and complainant after treatment was discharged on 11.10.2012 from the said hospital and she had to take post hospitalization treatment, in that case she incurred a sum of Rs. 8,232.62 paisa and expenses for post hospitalization was not contrary to the clause No. 3.7 of the said policy.
After admission of the complaint, her husband Arun Kumar Chakraborty reported the matter to TPA to settle the expenses for hospitalization though cashless method but the TPA refused to do so.But after discharge from the hospital, complainant had to go through post hospitalization treatment/operation for which she failed to file a complaint in time and complainant’s claim for reimbursement of the mediclaim documents were lodged on 04.12.2012 before TPA being claim form No. 0124-4466600.
But till today the matter has not been properly decided and fact remains that no amount has been released in favour of the complainant though ops are duty bound to perform their part of performance as per policy condition and for not disposing of the matter and for not releasing the said amount, complainant is being harassed by the ops and for which for negligence and deficient manner of service this complaint is filed.
On the other hand op by filing written statement submitted that the patient was admitted on 10.10.2012 in one Medica Super Speciality Hospital with complaint of percutaneous discolysis (C5-6) and on examination it was diagnosed that Fibromyalgia Cervical Vadiculopathy right sided due to PIVDC5-6 and was discharged with advise on next day of 11.10.2012 complainant claimed total amount of Rs. 82,797/-.
Fact remains that policy was 2nd year running and mentioned disease has two years waiting period as per Happy Family Silver Plan.Therefore TPA recommended the claim for repudiation under Exclusion Clause No. 4.3 and as because the claim is non-disbursable and it was repudiated under Exclusion Clause No.4.3 when the policy document is a contract and it has to be strictly followed by both the parties.So, the allegation of the complainant is false and fabricated and for which the present complaint should be dismissed.
Decision with reasons
On proper consideration of the argument as advanced by the Ld. Lawyer for both the parties and also considering the complaint and written version and also the terms and conditions of the policy Happy Family Floater Policy, it is found that Exclusion Caluse No.4.3 is applicable in respect of 22 items where the insured is not entitled to get any relief or claim amount.
But after studying the said 23 items, we have gathered that the present treatment does not come under the purview of the said 24 items or Exclusion Clause No. 4.3.But it is completely one type of treatment for Fibromyalgia Cervical Vadiculopathy right sided due to PIVDC5-6 and in fact during treatment period, complainant was given percutaneous discolysis (C5-6) + cervical epidural injection and in fact complainant was admitted for percutaneous discolysis (C5-6).
But it is proved that prior to this admission appendicetomy in the 1996 oopherectomy, anal fissure were done in the year 1996 and MRI revealed C5-6 & C6-7 was detected and for which cervical epidural injection was given and it cannot be given in the house.In fact she was feeling much pain on her back for which she was admitted and treatment was done and as per diagnosis it is found that this treatment does not come under the purview of Exclusion Clause No. 4.3 but that was wrongly decided by the TPA.
In the above situation we find that the repudiation as made by the op is not legal and valid and for which we find that op must have to decide the claim as per this observation as said disease it does not come under the purview of Exclusion Clause No. 4.3 and to dispose of the claim of the complainant accordingly invariably within one month from the date of this order and to release the settlement of mediclaim of the complainant.
Accordingly this complaint succeeds.
Hence, it is
Ordered,
That the complaint be and the same is allowed on contest against the ops with cost of Rs.2,000/-.
Op Insurance Company is hereby directed to dispose of the mediclaim as made by the complainant within one month from the date of this order as the treatment does not come under the purview of Exclusion Clause No.4.3 and so op shall have to dispose of the said claim of the complainant as already received by the op’s TPA on 04.12.2012 being Claim No.0124-4466600 and if ops do not dispose of the claim of the complainant within one month from the date of this order, in that case op Insurance Company shall have to pay a consolidated amount of Rs. 55,000/- to the complainant without any further delay and even if it is found that ops are unwilling to comply the order, in that case, penal action shall be started against them for which further penalty and fine shall be imposed upon the ops.
