The case of the complainant in short is that the complainant has a mediclaim policy with the New India Assurance Co.Ltd vide policy no. 51250334160100000035 since 20.04.2009. The Policy was renewed on 18.04.2016 . The period of insurance was from 20.4.2016 to 19.4.2017. The complainant felt burning pain in both lower limbs in the month of November, 2015. On 16.4.2016 the complainant visited Dr. Vikash Kapoor in Medica Superspeciality hospital for proper treatment. Dr. Kapoor prescribed some medicine but the complainant did not recover by taking that medicine. Thereafter, the complainant consulted with Dr. L.N.Tripathy in Medica Superspeciality hospital and as per advice of Dr. Tripathy the complainant got admitted in the said hospital on 12.5.2016 . Treatment and examination including MRI & X-ray was held upon complainant and the complainant was discharged on 18.5.2016. The total bill amounting to Rs.45,633/- was charged upon the complainant during the staying in hospital in between 12.5.16 and 18.5.16. Thereafter, the complainant submitted all documents related to her treatment on
28.6.2016 before the New India Assurance Co. Ltd. But unfortunately, on 19.8.2016 the Op repudiated the claim of the complainant. Hence this complaint.
The Opposite party entered appearance by filing Written version denying inter alia all material allegations. The positive case of the oP is that on scrutinizing the claim it appared that the patient was admitted with FIBROMYALGIA Syndrome with Psychiatric signs and symptoms in background as would be clearly established from the “Advice on Discharge”, on the face of Discharge Summary dated 18.5.2016 of Meica Superspeciality hospital. It was also clearly evident that the patient was admitted primarily for investigation purpose with no active treatment done other than taking Psychiatric medicines in oral forms and that being so the claim was not permissible vide clause no. 4.4.11 which specifically states that “Diagnosis, X-ray or laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury for …..” and the claim of the complainant further was repudiable under exclusion clause no. 4.6.1 . The Op prays for dismissal of the complaint.
Op no.4 entered appearance by filing Written version denying inter alia all material allegations. This Opposite states that on a perusal of the complaint it
would appear that no relief has been claimed against this Opposite party , so they pray for dismissal of the complainant against them.
Complainant filed photo copy of Mediclaim polcy , Photo copy of receipt cum adjustment voucher , photo copy of prescription dated 12.5.16, photo copy of discharge certificate dated 18.5.2016, Photo copy of MRI date4 12.5.16, photo copy of medical examination and photo copy of prescriptions etc. The complainant also filed Evidence in chief and W.N.A. The Op also filed photo copy of policy . The Op also filed Affidavit in chief and W.N.A.
Upon pleadings, Written version and the documents filed by all the parties the following points are framed for proper adjudication of this case.
Points
- Whether the petitioner is a Consumer ?
- Whether there is any deficiency in service on the part of the oP ?
- Whether the complainant is entitled to get relief as prayed for ?
DECISION WITH REASONS
All the points are taken together for easiness of discussion.
This case has been engineered by the complainant for getting the expenses regarding treatment of disease vis a vis some pathological and other instrumental
test suggested by the doctor, under Mediclaim policy 2007. The introduction of this policy has laid down in the preface and objective of the policy. For the sake of convenience the same portion is quoted herein for onwards consideration. The policy runs “ WHEREAS THE insured designated in the Schedule hereto has by a Proposal and declaration, dated as stated in the Schedule, which shall be the basis of this Contract and is deemed to be incorporated herein, has applied to THE NEW INIA ASSURANCE COMPAY LTD. (hereinafter called the COMPANY) for the insurance hereinafter set forth in respect of person(s) named in the Schedule hereto (hereinafter called the INSURED PERSON) and has paid premium as consideration for such insurance.
- Coverage : NOW THIS P[OLICY WITNESSES that, subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon, the company undertakes that if during the period stated in the Schedule or during the period stated in the Schedule or during the continuance of this policy by renewal any insured Person shall contract any disease or suffer from any illness (hereinafter called DISEASE) or sustain any bodily injury through accident (hereinafter called INJURY) and if such disease or injury shall require any such insured Person, upon the advice
of a duly qualified Physician/Medical Specialist/Medical Surgeon (hereinafter called SURGEON) to incur Hospitalisation Expenses (herein defined) for medical/surgical treatment at a Nursing Home/Hospital in India as herein defined (hereinafter called HOSPITAL/NURSING HOME/DAY CARE CENTRE) as an in patient, the Company will pay to the Hospital/Nursing Home or reimburse the insured person, through the Third Party Administrator, amount of such expenses as would fall under different heads mentioned below and are reasonably, customarily and necessarily incurred in respect thereof by or on behalf of such Insured Person but not exceeding in any one period of insurance the amount stated hereunder.
In the instant case the patient was admitted under the doctor L.N.Tripathy and Ors from 12.5.2016 and discharge date was 18.5.2016. Age of the patient was 45 years. After investigation the patient was discharged on 18.5.2016 with medicines. From the argument of the Op as well as argument of the complainant it is undenial fact that patient was not admitted and investigation was done for six days. The Opposite party cannot take the plea of no active treatment other than taking psychiatric medicines in oral form and thus argued for considering the case within the purview of exclusion clause 4.4.11 and 4.4.6 . But the material
produced in the record mainly discharge summary and other investigation report that to reach a final diagnosis those tests were required for conducting investigation over the body of the patient. There is not dispute that the complainant has no policy at the time of treatment. The plea of the Op/Insurance company by rejecting the prayer of complainant for expenses incurred by the complainant is totally against the objective of the Mediclaim Policy. Even the Government of India are taking regular step for making Health Insurance of all the citizens only for the benefit of the people in accordance with the directive principle of the State Policy to act for the Welfare of the people as per Preamble of Indian Constitution and Directive principles of State policy. So, at this juncture , the Op has crossed and neglected his duty towards the ailing female citizen of India. Such, refusal on the part of the oP on the ground only mentioned in 4.4.11 and 4.4.6 of the policy is totally not in accordance with the objectives of the Mediclaim policy . By refusing the claim the India Insurance Co. Ltd has violated the expressed provision of Insurance Act and objective of the Mediclaim policy 2007. So, the absolutely guilty of negligence and acting without any due care and attention for the welfare of the common man regarding treatment. The OP has deprived the beneficiary of this Insurance policy. The complainant shall be
compensated not with the cost of treatment but for mental , physical harassment. Accordingly we are of strong conviction as per material on record that the complainant is entitled to get redressal as per prayer . Hence it is –
Ordered
That the Complaint Case no. 206 of 2016 be and the same is allowed . The Opposite party no.1, 2 and 3 are directed to pay Rs.45,633/- to the complainant for her treatment in Medica Superspeciality Hospital. The OP no.1 , 2 and 3 are also directed to pay Rs.25,000/- to the complainant towards mental agony, pain and harassment. The Op no.1 ,2 and 3 are further directed to pay Rs.10,000/- to the complainant towards litigation cost.
The Opposite party no.1 , 2 and 3 shall comply the above order within 30 days from the date of this order i.d. after the statutory period of 30 days, Rs.200/- per day shall be imposed upon the Op no.1,2 and 3 and that amount will be deposited in the Consumer Legal Aid Fund.
Let a copy of this order be made over to the parties free of cost.
