Order No. 17 dt. 08/11/2017
The case of the complainant in brief is that the complainant opened a mediclaim policy under the policy name ‘Individual Mediclaim’ bearing policy no.350 in the name of the complainant as well as his parents under the Oriental Insurance Co. Ltd. for a sum of Rs.90,000/- as coverage option for the year 1999-2000. The complainant paid the policy premium. Accordingly the policy coverage option for the year 2001-2001 was increased and subsequently for the year 2013-2015 it reached to Rs.4 lakhs. On 16.8.14 the complainant fell ill and he was admitted to Kothari Medical Centre and as per the advice of doctor of the said hospital the complainant was treated and he was discharged from the said hospital after payment of the amount of Rs.35,319/-. The complainant after recovery asked for reimbursement of the medical bills, but the same was denied by o.ps. for which the complainant filed this case praying for direction upon the o.p. insurance company for releasing the fund of Rs.35,319/- as well as compensation of Rs.1 lakh and litigation cost of Rs.20,000/-.
The o.p. no.1 contested in this case by filing w/v and denied all the material allegations of the complaint. It was stated that the claim made by the complainant is not admissible according to law as the complainant is not entitled to get any claim since the complainant was admitted in the said hospital for evaluation purpose. There was no active line of treatment. As per investigation done by the TPA it was noted that the O/E temp. was 98.7 degrees Fahrenheit during emergency evaluation. As per temperature chart, maximum average temperature recorded was 98.4 degrees Fahrenheit, which is a febrile state. As per certification by Dr. Amitabha Sarkar dt.31.10.14 patient had features of dehydration, leg cramps along with fever, but, however, case history sheet of the patient does not show any such complaints recorded neither were any signs of dehydration was noted on records. Said certifying doctor was also not the treating doctor of the patient as per available records. On the basis of the said fact it was stated emphatically by o.p. no.1 that the admission of the patient was only for diagnostic purpose. Only the time of hospitalization cannot be reasons enough for making the alleged claim admissible. Accordingly as per clause 4.11 of the policy the claim of the complainant was repudiated. There was no deficiency in service on the part of o.p. insurance company and accordingly o.p. insurance company prayed for dismissal of the case.
In spite of receipt of notices the o.p. nos.2 and 3 did not contest this case by filing w/v and as such, the case has proceeded ex parte against them.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with o.p. insurance company at the relevant point of time?
- Whether the complainant was admitted to the said hospital for the purpose of his illness?
- Whether the complainant took admission to the hospital for investigation purpose?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant opened a mediclaim policy under the policy name ‘Individual Mediclaim’ bearing policy no.350 in the name of the complainant as well as his parents under the Oriental Insurance Co. Ltd. for a sum of Rs.90,000/- as coverage option for the year 1999-2000. The complainant paid the policy premium. Accordingly the policy coverage option for the year 2001-2001 was increased and subsequently for the year 2013-2015 it reached to Rs.4 lakhs. On 16.8.14 the complainant fell ill and he was admitted to Kothari Medical Centre and as per the advice of doctor of the said hospital the complainant was treated and he was discharged from the said hospital after payment of the amount of Rs.35,319/-. The complainant after recovery asked for reimbursement of the medical bills, but the same was denied by o.ps. for which the complainant filed this case praying for direction upon the o.p. insurance company for releasing the fund of Rs.35,319/- as well as other reliefs.
Ld. lawyer for the o.p. no.1 argued that the claim made by the complainant is not admissible according to law as the complainant is not entitled to get any claim since the complainant was admitted in the said hospital for evaluation purpose. There was no active line of treatment. As per investigation done by the TPA it was noted that the O/E temp. was 98.7 degrees Fahrenheit during emergency evaluation. As per temperature chart, maximum average temperature recorded was 98.4 degrees Fahrenheit, which is a febrile state. As per certification by Dr. Amitabha Sarkar dt.31.10.14 patient had features of dehydration, leg cramps along with fever, but, however, case history sheet of the patient does not show any such complaints recorded neither were any signs of dehydration was noted on records. Said certifying doctor was also not the treating doctor of the patient as per available records. On the basis of the said fact it was stated emphatically by o.p. no.1 that the admission of the patient was only for diagnostic purpose. Only the time of hospitalization cannot be reasons enough for making the alleged claim admissible. Accordingly as per clause 4.11 of the policy the claim of the complainant was repudiated. There was no deficiency in service on the part of o.p. insurance company and accordingly o.p. insurance company prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant got admission in the said hospital for treatment and it is also an admitted fact that the policy was valid at the relevant point of time. After recovery the complainant claimed for reimbursement of the medical bills to the tune of Rs.35,319/-. The complainant at the time of submission of the medical bills provided all the documents. On behalf of the insurance company TPA examined the said medical bills and after scrutinizing the documents it was found that the complainant got admission in the said hospital for the purpose of investigation of some problems faced by him. There was no actual treatment rendered by the hospital to the complainant. On the basis of the said fact insurance company after getting the claim from the complainant informed him that the terms and conditions of the policy does not cover the claim made by the complainant. Accordingly the claim of the complainant was repudiated. On perusal of the materials on record included the policy papers it appears that it was clearly stated in the policy itself that as per clause 4.11 the complainant will not be entitled to get any claim as prayed by him. The insurance company after perusal of the documents filed by the complainant along with the terms and conditions of the policy rightly repudiated the claim of the complainant. There was no deficiency in service on the part of o.p. insurance company. Thereby we hold that the case filed by the complainant has got no merit and as such, the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.112/2015 is dismissed on contest against the o.p. no.1 and dismissed ex parte against other o.ps. without cost.
Supply certified copy of this order to the parties free of cost.
