By Smt.Padmini Sudheesh, President
The case is that the complainant has taken individual medi claim policy from the respondents for the period from 7/3/06 to 6/3/07. On 4/11/06 the complainant was admitted at PNVM hospital, Ernakulam with complaints of chest pain. He was discharged on 5/11/06. He was treated for one day at the hospital. After the discharge he is applied to get treatment expenses from the 1st respondent for Rs.5,995/-. But it was rejected by stating that there was no treatment but investigation only. This act of respondent is deficiency in service. Hence the complaint.
2. The version of 1st respondent is that the respondents admits the policy covering the insured for a sum of Rs.20,000/- for hospitalization and medical expenses subject to the terms and conditions of the policy. The policy covers only hospitalization expenses for illness or injury sustained. The treatment for investigation of illness does not come under the purview of the policy. The insured has filed a claim and it has been settled for a sum of Rs.8,105/-. The present claim does not come under the policy. The investigations could have been done on out patient basis without the necessity of admission. Hence the claim of complainant was repudiated. There is no deficiency in service from this respondent.
3.The 2nd respondent remains exparte.
4. Points for consideration are that :
1) Whether there was any deficiency in service from the respondent ?
2) If so reliefs and costs ?
5. Evidence adduced consists of oral testimony of PW1, Exhibits P1 to P5 series and Exhibits R1 to R4.
6. The complaint is filed to get reimbursement of medical expenses incurred to complainant.
7. It is the case of complainant that he has admitted at PNVM hospital, Ernakulam with complaints of chest pain. On the very next day he was discharged. But he was admitted for one day. Accordingly there occurred Rs.5,995/- as treatment expenses and the complainant submitted claim to 1st respondent to get the amount. But the company has repudiated the claim of complainant by stating that the treatment for investigation of illness does not come under the policy.
8. The complainant is examined as PW1. It is his version that he has been admitted at the hospital with complaints of chest pain and not for investigating the disease. It is his case that he was admitted for treatment of disease and not for the investigation. But there is no prescriptions produced to show the treatment given by the doctor or to show the medicines prescribed. He has produced Exhibit P5 discharge summary by which it can be seen that 18 types of tablets were prescribed by the doctor and advised to take rest for 2 months. It is interesting to note that if the disease was such a serious one he would not have discharged after one day. Here the admission is only for one day and 18 types of tablets were prescribed by the doctor. I suspect the credibility of Exhibit P5. If the disease was such a serious stage the admission for one day will not be sufficient.
9. It is the contention of 1st respondent that the policy will be covered only for treatment expenses and not for investigation charges. This respondent produced policy with terms and conditions and shows the same. The records would show that the hospitalization of complainant was for investigation of the ailment only. So as per the terms and conditions of the policy the complainant is not entitled to get any amount.
10. In the result the complaint stands dismissed.
Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 8th day of June 2012.
