O  R D E R

SRI. D.KRISHNAPPA., PRESIDENT.,

          Brief facts of the complaint filed by the complainant against the OP are, that she had availed a Mediclaim policy from the OP. Due to an ailment, she got herself admitted to Sagar hospital, Bangalore and she was diagnosed for severe neck pain in her left upper limb and took treatment as an inpatient from 6-11-2009 to 9-11-2009. She was having Mediclaim policy for entire family from last five years and has not made single claim so far. She had cashless facilities but paid hospital charges and made a claim for reimbursement of Rs.48,808/- from the OP but her claim came to be repudiated on the ground that she has only undergone tests, not followed with the treatment. Thereby has prayed for a direction to the OP to reimburse her medical expenditure.

          2. OP has appeared through his advocate and filed version, admitting issue of policy in favour of the complainant, which was in effect from 28-3-2009 to 27-3-2010. It is further contended that treatment under gone by the complainant is only investigation and doctor consultation without any active line of treatment requiring hospitalization. Therefore justified the repudiation of the claim of the complainant by invoking exclusion clause 4.10 of the conditions of the policy. OP further contending that the ailment of the complainant had not required hospitalization of the complainant, undergone only investigation, as per the discharge summary of the hospital. The OP further contending that no active treatment was followed in the hospital and stated that hospital bill refers to about Rs.36,180/- whereas the receipts enclosed to the bill dated 9-11-2009 refers to the treatment and consultation, which are not related to the hospitalization and therefore submitted for dismissal of the complaint.

          3. In the course of enquiry into the complaint, the complainant and the OP have filed their affidavit evidence reproducing what they have stated in their respective complaint and version. The complainant alongwith the complaint has produced a copy of letter addressed by the Regional Manager of the OP to her, copy of letter she had addressed to the third party administrator of the OP, copy of opinion letter of Sagar hospital, copy of repudiation letter, discharge summary of the hospital, with copies of reports of some tests that the complainant undergone, besides producing copy of hospital bill. OP also has produced copy of discharge summary, terms and conditions of Mediclaim insurance policy and copy of repudiation letter. The counsel for the complainant has produced written arguments. We have heard the counsel for the OP and perused the records. The complainant in the affidavit evidence and written arguments filed has claimed for reimbursement of Rs.36,180/- with interest at 18% per annum from the date of discharge up to date of payment and to award a sum Rs.1,00,000/- as compensation.

          4. On the above contentions, following points for determination arise.

1)     Whether the complainant proves that the OP has caused deficiency in his service by repudiating the claim of the complainant to reimburse the medial expenditure, she has incurred?

2)     To what reliefs, the complainant is entitled to?

5. Our findings are as under:

Point no.1: In the affirmative

Point no.2: See the final Order

REASONS

          6. Answer on Point No.1:  The claim of the complainant that she had availed a Mediclaim insurance policy from the OP, which was valid from 28-3-2009 to 27-3-2010, that she underwent treatment for her Cervical Spondylosis, which was acute onset, progressive in nature as inpatient from 6-11-2009 to 9-11-2009 is not in dispute between the parties. But the claim of the complainant for reimbursement of her medical expenditure amounting to Rs.48,808/-  was repudiated by the OP through their repudiation letter dated 13-1-2010 by invoking exclusion clause 4.10 of the policy conditions, on the ground that the complainant has undergone only investigation and Doctor Consultation without any active line of treatment requiring hospitalization. The complainant had questioned the correctness of repudiation of her claim in this complaint. The OP justifying his action in repudiating the claim has submitted for dismissal of the complaint. Therefore, we shall examine, whether repudiation is based on the clause 4.10 of the conditions of the policy is proper.

7. Exclusion clause 4.10 of the conditions of the policy, reads as under:

“4.10-Expenses incurred at Hospital or Nursing Home primarily for evaluation /diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period.”

          8. This exclusion says that expenses incurred at hospital or nursing home primarily for diagnostic purposes, which is not followed by active treatment, is excluded, which goes to show if the insured has only undergone a process for diagnostic purposes not followed by treatment, such expenditure incurred is excluded under the policy. On going through the contents of discharge summary and hospital records, they reveal that the complainant who is a known case of type 2 diabetes mellitus having acute neck pain radiating to left upper limb which was progressive in nature approached Sagar hospital, where the doctors after assessing the severity of the ailment of the complainant advised for admission for detail investigation. Then after all the investigation, the doctors followed treatment and treated her for acute Cervical Spondylosis by administering medicine like Pregalin/Eliwel/Pamtodac and other supportive measure and with that follow up treatment the complainant was found stable and was discharge on 9-11-2009. Therefore, it is not that the complainant had only got her ailment investigated through tests and was discharged from the hospital. She after getting her ailment diagnosed was under treatment by follow up administering tablets and then she was discharged. Considering this fact borne out from the discharge summary, contention of the OP that diagnosis did not follow with treatment for that ailment cannot be accepted.

          9. The OP further stated to had relied upon the opinion of their panel doctors and has contended that ailment of the complainant did not warrant hospitalization.  We do not think it is for the OP or their penal doctors to say whether the particular ailment or patient required hospital are not when a patient the insured with a problem of Cervical Spondylosis was suffering from acute neck pain which was progressive and known case of diabetic mellitus type 2, it is for that patient to decide on the advice of the treating doctor either to get himself or herself admitted to get the relief. Again it is the opinion of treating doctor who after considering severeness of the ailment of the patient to decide whether hospitalization is required or not.  In the case on hand both advising doctor and the patient felt that in order to have proper tests and diagnosis, they decided to admit to hospital.  Accordingly, she was admitted as inpatient and after all continued tests with treatment was discharged.   Thus, we in the instant case find that the complainant after getting her ailment diagnosed took treatment for subsiding that ailment as a inpatient and therefore, clause 4.10 of exclusion clause is not applicable to the facts of the case. Thus repudiation of the claim of the complainant by OP, in our view amounts to deficiency in his service.

10. The complainant besides producing a copy of bill of the hospital amounting to Rs.36,180/-, also produced copies of few more bills which are of earlier to 6-11-2009 which are not admissible. However, the complainant in the affidavit and written arguments claimed Rs.35,180/- that amount is not disputed by the OP. Therefore, the complainant is entitled for reimbursement of that money. The complainant has not substantiated her claim for awarding compensation of Rs.1,00,000/-. However, we having held that repudiation is not in accordance with the law we answer point No.1 in the affirmative and pass the following order:

O R D E R

Complaint is allowed. OP is ordered to reimburse Rs.35,180/- (Rupees Thirty Five Thousand One Hundred Eighty only) to the complainant with interest @ 7% per annum from 17-11-2009 on which date of the claim was made upto the date of payment.

OP shall also pay cost of Rs.3,000/- (Rupees Three Thousand only) to the complainant.