Complainant Vinod Kumar Sharma by filing this complaint has submitted that complainant holds a Health Insurance Policy since 2002 under the op after renew it since 2002 without any break and said policy was valid having Policy No. 71250034112100000010/GH/FEB 12/08688 and when the said policy was valid, complainant suddenly fell on the foot path and sustained head injury and lost his consciousness and was hospitalized at Apollo Gleneagles Hospitals, 58, Canal Circular Road, Kolkata – 700054 for treatment of his head injury and since 20.10.2012 to 21.10.2012 he was treated at that hospital.  Thereafter he was discharged with direction for further examination etc.  After discharge from the said hospital, complainant intimated the aforesaid fact to op no.2 under their reference No. POL 6712010.

          Thereafter on 25.10.2012 complainant after consultation with Dr. Anjan Siotia regarding headache, he was further advised to undergo some investigations and was advised for a treatment under Neurosurgeon and accordingly he consulted with Vinod Kumar Singhania at Apollo Gleneagles Hospitals who after check-up suggested some medicines for quick recovery and for such treatment complainant spent Rs.15,326.10/- for his treatment and as because he filed to comply for cashless facility with op no.2 during treatment hours.  But op rejected the claim on the ground that the expenses on hospitalization for minimum period for 24 hours only are admissible and only expenses which are directly related to illness for which the hospitalization shall be considered and on receipt of that complainant was shocked and surprised and again prayed for release of the said amount but that was rejected.  In the present complaint complainant has prayed for relief.

          On the other hand op by filing written statement submitted that he was hospitalized at Apollo Gleneagles Hospital on 20.10.2012 at 08:49 PM for sudden loss of consciousness (SYNCOPE) and was released on 12:04 PM and practically he was in the hospital for 4 hours i.e. less than 24 hours and such type of ailment cannot be covered under day-care and he was released at stable condition as the injury was very minor in nature.

          As per Clause-2.3, Hospitalisation Benefit means medical treatment for a period not less than 24 hours for such illness/disease/injury which requires care and treatment at the hospital/nursing home.  And as per Clause-2.3.1 expenses on hospitalization for minimum period of 24 hours are admissible.  However, this time limit for specific treatments such as Haemo-Dialysis, Parenteral Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Kidney Stone removal, Tonsillectomy only.

          Accordingly as per provision of Clause-2.3 and 2.3.1 of the subject policy the same claim was rejected.  But even then op has submitted them sympathetically considered the claim and settled to some extent of Rs.9,476/- and the op is ready to pay as full satisfaction and in the above circumstances, the complainant entire complaint is not tenable in the eye of law, but complainant may accept the amount of Rs.9,476/- and the op is ready to pay it and for which the present complaint should be dismissed.

                                                Decision with reasons

          On proper evaluation of the entire policy and the period of terms and the complainant has reflected in the complaint and written version including the documents as produced by the complainant and also after considering it by the Ld. Lawyers for both the parties we have gathered that complainant was not in the hospital for more than 24 hours for treatment.  But he was treated at the hospital of Apollo Gleneagles Hospital on 20.10.2012 for only for 4 hours.  Thereafter, he was never hospitalized and regarding the consultation fee invariably complainant is not entitled to get such benefit as per Insurance Policy which is very much clear.

          Further considering the policy conditions, it is clear that as per policy condition Clause-2.3 and 2.3.1 complainant is not entitled to such benefit of mediclaim as treatment period was less than 24 hours.  But anyhow op admitted in his written statement that they have taken a sympathetic view though the complainant is not entitled to get any benefit as per contract but they have settled the same by paying Rs. 9,476/- and op is ready to pay the same to the complainant on full satisfaction of the claim and that paper is also filed by the op.  But complainant is not willing to accept it.  But in this regard, we have gone through the entire terms and conditions attached to and from any part and made medi-claim policy (Form NO.GH-08 10) it is clear that complainant is not entitled to claim beyond the terms and conditions of the policy and that is settled principle of law and truth is that this Forum cannot entertain any language or word or sentence to give relief to the complainant when the complainant is bound by the terms and conditions of the policy and fact remains that complainant’s treatment was only 4 to 5 hours and he was discharged on the same day by the doctor of the hospital treated as stable.  Thereafter he was never hospitalized.  So, the claim of the complainant is not entertainable in the eye of law but as op has his willing to pay on humanitarian ground and taking a sympathetic view to the extent of Rs.9,476/-.  So we are directing to complainant to receive it as final settled in respect of his claim and accordingly the complaint is disposed of finally because further relief cannot be granted by this Forum.  In view of the fact the Forum is bound by terms and conditions of the policy and as per terms and conditions of the policy we cannot allow the claim of the complainant.

          In the result, the complaint succeeds as per admission of the op in part.

          Hence, it is

                                                       ORDERED

          That the complaint be and the same is allowed on admission of the op and dispose of accordingly in final form without any cost against the ops in view of the above findings.

          Op is directed to pay the said amount of Rs.9,476/- to the complainant within one month and without any fail and without waiting for any delay positively from the date of this order.