ORDER

Per NUPUR CHANDNA, MEMBER



   The complainant is the holder of a mediclaim policy issued by OP.
The policy was valid for the period 22.8.2013 to 21.8.2014.  It has
been alleged by the complainant that on 25.12.2013 , he was admitted
in Max Hospital for surgery/ operation of Hernia. After surgery,  he
was discharged on 27.12.2013 and the OP company had paid all the bills
of hospitalization and medicines to the complainant.   It is alleged
by the complainant that after discharge because of certain changes in
medicine by the concerned doctor he was feeling unwell and hence he
was again admitted in Max Hospital in the night of 30-12-2013 and was
discharged on 31-12-2013 as soon as his condition become unstable.
The complainant submitted the medical bills and record f hospital of
30/12/2013 to the OP but the OP did not pay the claim under the
pretext that it will pay/ reimburse the same ony if the complainant
brings in writing from the treating doctor that problem suffered by
the complainant is on 30-12-2013 was related to the operational
consequences. The complainant got the same in writing from the
treating doctor that his hospitalization was a follow up  of the
earlier hospitalization. Therefater the complainant approached the OP
several times for reimbursement of the after said amount,but the OP
company always postponed the same on one pretext or another.  It is
further alleged by the complainant that the TPA of the OP company had
approved the claim of Rs 3221/- and disallowed Rs. 3021/- as not
admissible under clause 4.4.11 of the policy terms and conditions.

        The complainant has alleged that this act of OP was uncalled
for and amounts to deficiency in services and has therefore approached
this forum with the present complaint.

    The OP has contested the complaint and has denied any deficiency
on its part  filed on written statement. It has denied any deficiency
on its part and has claimed that complaint has no merit and is liable
to be dismissed. Preliminary objection no. 3 of the written statement
is relevant for the purpose of decision of this complaint and is
reproduced as under:-

1.    That there is no deficiency of service on the part of the
answering respondent in not paying alleged amount of Rs., 10,000/-
though the main claim amount of Rs. 65,630/- for left inguinal hernia
has been allowed. It may be mentioned that the complainant thereafter
lodged a claim for Rs. 6 142/- as per claim form but as per legal
notice and the complaint, it is alleged that the claim has been filed
for Rs. 10,000/-. The TPA of the opposite party has approved the claim
for Rs. 3221/- as per terms and conditions of insurance policy no.
32030134132500000074 (annexure A) and disallowed Rs. 302 1/- as not
admissible as detailed in their letter dated 20.12.14 (Annexure B ).
The complainant was admitted in the hospital for the second time for 2
hours on account of mild headache which is related to hypertension as
per initial assessment sheet of Max Health care annexure C). The
complainant is a chronic patient of hypertension for the last 20 years
and the same has nothing to do with hernia for which the complainant
was hospitalized from 25.12.13 to27..12.13. As per policy clause
4.4.11 “charges incurred at Hospital primarily for diagnosis, x-ray or
laboratory examinations of other diagnostic studies not consistent
with or incidental to the diagnosis and treatment or positive
existence or presence of any illness or injury for which confinement
is required in a hospital.” Hence the complaint is not maintainable
under the Consumer Protection Act and is liable to be dismissed.

Both the parties have placed on record their evidence by way of affidavit.

     We have heard arguments advanced at the bar and have perused the record.

     We have considered the letter dated 28-12-2014 which has been
addressed to the Senior Divisional Manager of the OP Insurance company
by its TPA.  The complainant ha lodged a claim of Rs 6,242/- out of
which a sum of Rs 3,221/- had been paid while disallowing the claim of
Rs. 3,021/-.  The letter dated 20/12/2014 spells out the reason for
disallowing this claim.   The claim was primarily for post
hospitalization treatement.  The TPA has claimd that the patient’s
condition was probably due to increase in high blood pressure and thus
the claim was not payable.  On a consideration of the facts, we are
not convinced with the reasons given by TPA for disallowing the
aforesaid claim.  The opinion of the TPA is based on assumptions and
conjecture.  It cannot be said with certainty that whenever a patient
has headache , it is always due to high Blood Pressure on a day of
admission on 30/12/2013 the Blood Pressure of the patient wasnot high
as per the initial assessment.

     We have seen the treatment record, which clearly shows that on
the day of admission of the insured in the hospital on 30/12/2013, his
blood pressure was not very high and was within permissible limit.
Ex. CW1/2 is a certificate issued by the treating doctor  of the Max
hospital.  It appears to us that the OP has not taken the certificate
into consideration while repudiating the claim. We are therefore, of
the considered opinion that the OP ought not to have repudiate the
claim in respect of the expense incurred by the insured on his
hospitalization on 30/12/2013 and 31/12/203. We hold that the OP was
deficient in rendering the services to the complainant and direct it
as under:-

     1.Pay to the complainant  a sum of Rs 3021 /- along with interest
@ 10% p.a. from the date of institution of this complaint i.e.
27.8.2014  till payment.

2.Pay to the complainant a sum of Rs 10,000/-a s compensation for the
pain and agony suffered by him..

3.Pay to the complainant a sum of Rs. 5,000/- as cost of litigation.

       The OP shall pay this amount within a period of 30 days from
the date of this order failing which they shall be liable to pay
interest on the entire awarded amount @ 10% per annum.  IF the OP
fails to comply with this order, the complainant may approach this
Forum for execution of the order under Section 25/27 of the Consumer
Protection Act.





Copy of the order be made available to the parties as per rule.

    File be consigned to record room.

     Announced in open sitting of the Forum on.....................