By Smt. Padmini Sudheesh, President: The case of complainant is that the complainant taken a mediclaim insurance policy of 3rd respondent vide policy No.441100/2007/1872 through the 2nd respondent. Meanwhile on 19.6.2007 the complainant was admitted in the first respondent hospital for the treatment of urethral syndrome. She was discharged on 21.6.07 with direction to undergo treatment for one month. The complainant had incurred medical expenses for an amount of Rs.1600/-. After the treatment she applied to the 2nd respondent along all the relevant document through the first respondent. The 2nd respondent repudiated the claim by stating their inability to pay the amount. This is illegal and this complaint is filed. 2. The counter of 3rd respondent is to the effect that this respondent has issued a mediclaim hospitalization insurance policy which covers hospitalization expenses reasonably and necessarily incurred by the insured person. As per this policy if any insured person contract any disease or suffer from any illness which shall require upon the advice of a duly qualified medical practitioner hospitalization. The claim of complainant does not come under the purview of the policy. The complaints of the complainant were dysurea of one month’s duration which was diagnosed as urethral syndrome. Other than investigation X-ray/Ad6.KUB and medicines, no active treatment has been undergone by the complainant which warranted hospitalization. There is no justification for hospitalized treatment as the investigation and medicines could be availed as an outpatient. It is also learnt that oral medicines are only prescribed and no treatment requiring compulsory hospitalization is noted. Clause 4.10 states that “Expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalization period” is exclusion under the policy. The claim is repudiated on the above ground. No active treatment is given to the complainant which warranted hospitalization. The claim is repudiated by the 2nd respondent under just grounds. Every claim is sent to the 2nd respondent and it is the 2nd respondent after investigation and enquiry repudiate or favour the claim. The claim is repudiated by the 2nd respondent under clause 4.10 of the policy. The complainant is not entitled to get Rs.1600/-. This respondent is not liable to pay any amount. Hence dismiss. 3. The other respondents remained exparte. 4. The points for consideration are: (1) Is there any deficiency in service on the part of respondents? (2) If so, reliefs and costs. 5. The evidence consists of Exts. P1 and P2 on the part of complainant and Exts. R1 to R5 on the part of 3rd respondent. No oral evidence adduced by both. 6. Points: This complaint is filed to get reimbursement of the medical expenses incurred to the complainant. According to the complainant, she was admitted in the first respondent hospital on 19.6.07 with complaints of Urethral Syndrome and discharged on 21.6.07 with direction to continue the treatment for one month. She states that she had incurred medical expenses of Rs.1600/-. According to her, being a mediclaim insurance policy holder she will be entitled for the reimbursement of this expense and she preferred claim to the 2nd respondent through first respondent. But it was repudiated by the 2nd respondent. She has filed only Exts. P1 and P2 documents to prove her case. She has not adduced any oral evidence. 7. In the counter, the 3rd respondent insurance company admitted the policy and stated that if any insured person contract any disease or suffer from any illness which shall require upon the advice of a duly qualified medical practitioner hospitalization. Ext. R3 the discharge summary would show that she was admitted by the advice of Dr. Antrony P.G., MS MCH with the complaints of Dysuria. As per Ext. R3 detailed investigations were seen done. All the investigations were on 19.6.07 the day of admission itself. As per Ext. R3 there was no treatment given to the complainant. In the discharge summary it is stated that investigations shown no abnormality and so no treatment was given. There was advice of discharge but no treatment was given at the time of hospitalization. So it can be realized that there was no need for hospitalization. All the tests were done on the date of admission itself and there is no necessity of hospitalization. So as per the terms of the policy the complainant is not entitled for the reimbursement of medical expenses. The respondent produced Ext. R1 which contains the policy terms and conditions and it is specifically stated about this aspect. As per Clause 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 is exempted from the purview of the policy. As per the discharge summary there was no treatment at all done. 8. Ext. R4 the repudiation letter would show that since there is no justification for hospitalization treatment they are unable to honour the claim. It would also show no active treatment has been undergone by the complainant which warranted hospitalization. In the repudiation letter it is stated that the complainant happens to be an employee under the first respondent hospital. It is true that as per the complaint the complainant is an employee of the first respondent hospital. So she can easily get a hospitalization without treatment at all. The circumstances of the case would reveal that the complainant without any ailment was hospitalized. So she is not entitled to any amount from the respondents. There is no deficiency in service on the part of respondents and the complaint is liable to be dismissed. 9. In the result, the complaint stands dismissed. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 28th day of May 2010.
| | HONORABLE Rajani P.S., Member | HONORABLE Padmini Sudheesh, PRESIDENT | HONORABLE Sasidharan M.S, Member | | 
