PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

1)        The Complainant has prayed that the Opposite Parties be directed to pay Rs.38,699/- being the medical expenses incurred by the Complainant  it is also prayed that the Opposite Parties be directed to pay Rs.1,00,000/- with interest @ 18% p.a. from the date of filing of this complaint till its realization as special compensation for humiliation, mental agony and hardship suffered by the Complainant due to deficiency in service and negligence on the part of Opposite Parties.  The Complainant has also prayed for Rs.50,000/- towards litigation charges.

2)        According to the Complainant, he had obtained policy from the Opposite Parties for the period 27/01/2011 till 26/01/2012 and paid an amount of Rs.3,811/- as a premium to the Opposite Parties.  The copy of the said policy is at Exh.‘A’.  It is submitted that the said policy covered the Complainant and his family members.  The wife of the Complainant Mrs. Sushma Chourasiya had suffered giddiness and unconsciousness therefore, family doctor Mamniya had referred to her for further treatment vide letter dtd.27/10/2011 the copy of the said letter is marked as Exh.‘C’.  The wife of the Complainant as per the suggestion of the family doctor of the Complainant was referred to Balaji Hospital for further treatment.  She was admitted in the said hospital on 27/12/2011 and undergone various medical treatment for the illness. The wife of the Complainant was discharged by Balaji Hospital on 31/12/2011 by given conclusion that chest pain in her body and provided medicines to her.  The xerox copies of medical papers of Balaji Hospital are marked as Exh.‘D’. It is submitted that after the treatment from Balaji Hospital to the Complainant’s wife, the Complainant had raised bills for the said treatment to the Opposite Party of the payment made to the said hospital of Rs.38,699/-.  The copies of the said bills are marked as Exh.‘E’.  It is alleged that the Opposite Parties had not raised any objection regarding authenticity of policy issued to the Complainant.  The copy of the claim application lodged to the Opposite Party is marked as Exh.‘F’ which is dtd.06/01/2012.  It is the case of the Complainant that the Opposite Parties did not reimburse the said claim to the Complainant and thereby committed deficient service against the Complainant. The Complainant thereafter, issued notice to the Opposite Party through Advocate Yogesh Bamne on 04/09/2012.  The Opposite Parties did not reply to the said notice and failed to compensate the loss caused to the Complainant.  The correspondence regarding the notice issued through Advocate is marked as Exh.‘G’ & ‘H’.   It is submitted that the Opposite Parties had acted arbitrarily and therefore, they are liable for the reliefs claimed by the Complainant in para 1 of this order.

3)        The Opposite Parties contested the claim by filing written statement.  It is contended that the Complainant’s claim is misconceived and not maintainable against the Opposite Parties. According to the Opposite Parties the claim lodged by the Complainant is not payable under the policy terms and conditions.  It is not disputed that the Complainant had availed with family Health Optima Insurance Policy for the period 27/01/2011 to 26/01/2012.  It is also undisputed that the Opposite Parties had received the claim seeking re-imbursement of medical expenses for the treatment of IHD at Balaji Hospital, Mumbai.  It is however, contended that on scrutiny of medical record, the in-house medical experts of the Opposite Parties observed from the discharge summary that – 1. The diagnosis was of chest pain under anemia. 2. The insured patient was admitted with history of giddiness, fainting, burning over chest, omitting and cough and for which the investigations were carried out such as, 1. ECG,  2. TMT,  3. Troponin I  4. Ct Brain, etc.  It is contended that the medical record shows that the patient was admitted for investigation purpose only and no active treatment was given and only oral drugs were given.  It is submitted that the claim did not fall within the ambit of the policy and therefore the same was rejected as per exclusion clause no.13. The Complainant was accordingly informed vide repudiation letter dtd.03/02/2012.  It is submitted that upon receipt of the notice on behalf of the Complainant the claim was again reviewed and reply was sent by letter dtd.10/12/2013.  It is submitted that the Opposite Parties are not guilty of deficiency of service as averred by the Complainant.  The Opposite Parties are not liable to pay the claim made in the complaint.  It is submitted that the complaint be dismissed with cost.              

4)        The Complainant has filed his affidavit.  The Opposite Party has filed affidavit of Dr. Anita Pitale, Authorized Signatory of the Opposite Parties.  Both the parties filed their written arguments. We heard oral argument of Shri. Yogesh Bamne,  Ld.Advocate for the Complainant and Smt. Asita Parmar for the Opposite Party.  We placed the record produced by both sides.

5)        While considering the claim made in the complaint it is necessary to be considered that the Opposite Parties by letter at Exh.‘F’ filed with the complaint have specifically repudiated the claim by observing that the medical team of the Opposite Parties have observed from the investigation reports and hospital records including the discharge summary that during hospitalization no specific treatment was given to the insured person and the admission was mainly for investigation and evaluation purpose.  As per exclusion no.13 of the policy, the Company is not liable to make any payment for expenses incurred at Hospital. Primarily for diagnostic, X-ray, Laboratory Examinations not consistence with or for incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at the hospital/nursing home.  Considering the clause 13 of the insurance policy which is placed on record at Exh.A and the medical documents filed by the Complainant, we hold that as the Complainant had lodged the claim regarding reimbursement of the investigation carried out of his wife at Balaji Hospital, thus, the repudiation communicated by the Opposite Parties to the Complainant is justified in view of clause no.13 of the policy.  The submissions made by the Advocate for the Complainant relying upon the order of Chandigarh Ombudsman Centre, Case No.GIC/199/NIC/11/08, Ajit Singh V/s. National Insurance Co. Ltd., dtd.21/09/2007 cannot be accepted as the said case is not at all applicable to the facts of this case and the same is not binding on this Forum.  The other case relied by him of New India Assurance Co. Ltd. V/s. Pradip Kumar is also not applicable to the facts of this case.  The contention raised by the Opposite Parties that the policy of insurance is a contract and the parties are required to abide by the terms and conditions of the policy in our view is just and proper.  It is also not proper that the Court of Tribunal cannot make out of fresh case however, reasonable it may be.  In this case therefore, we find that the Complainant has failed to prove any deficiency of service on the part of the Opposite Parties for the grant of the reliefs claimed against the Opposite Parties.  We therefore, pass the following order –

O R D E R

                      i.       Complaint No.219/2012 is dismissed with no order as to costs.

                      ii.      Certified copies of this order be furnished to the parties.