The complainant’s case is as follows: The complainant is a policy holder of the respondent Insurance Company Bearing No.100605/48/06/41/00000189. On 20.1.07 the complainant got admitted in Thrissur Heart Hospital due to severe pain in the right side of the stomach. She was under treatment till 23.1.2007 and also continued treatment at home. When she applied for the medical claim the respondent repudiated the claim. The complainant spent Rs.3444.50 as hospital expenses and Rs.150.40 for the prescribed medicines. She is now also under treatment. The complainant is liable to get the insurance amount. Hence the complaint.

 

            2. The version filed by the respondent is as follows: The policy number mentioned in the complaint is a Group Mediclaim Tailor Made policy issued in favour of the Trichur Heart Hospital Health Club for 438 persons in which the claimant also is a member and its period of insurance is from 00:00 hrs. on 1.5.2006 to midnight of 30.4.2007. In this policy the details of the insured and the details of risks covered etc. are stated. The said policy is operative only subject to the terms andconditions stipulated therein. Accordingly if during the policy period stated in schedule or during the continuance of this policy by renewal any insured person shall contract any disease or suffer from any illness or sustain any bodily injury through accident and if such disease or injury shall require any such insured person upon the advice of a duly qualified Physician/Medical Specialist/Medical Practitioner or of a duly qualified surgeon to incur hospitalization/domiciliary hospitalization expenses for medical/surgical treatment at any nursing home/hospital; in India as herein defined as an inpatient, the Company will pay to the insured person the amount and such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person but not exceeding the sum insured in aggregate in any one period of insurance stated in the schedule. So the policy coverage is subject to the above conditions only other than those alleged in Para-1 of the complaint. This respondent denies that the claimant is treated as an inpatient at any where as claimed in the petition. She has undergone some medical check ups in the “Thrissur Heart Hospital” from 20.1.07 to 23.1.07 as I.P.No.42964, but not undergone any treatment as inpatient and after that she might have taken treatment as out patient but for which as per the policy conditions no claim is payable during those days. Therefore the policy is inoperative due to the above reasons and the complainant is not entitled for getting any amount of compensation or expenses as claimed. The reason for repudiation has been intimated to the insured vide letter dated 4.8.07 by this respondent in which it is specifically mentioned that “the treatment could have been taken as an out patient”. Whatever allegations in the complaint contrary to the statements above, with respect to the policy, treatment and alleged claims are false and hence denied. Hence dismiss.

 

            3. The points for consideration are:

 

(1)    Is there any deficiency in service?

(2)    If so, reliefs and costs.

 

            4. The evidence consists of Exts. P1 to P8 and Exts. R1 to R4.

 

            5. Points-1 & 2: The complaint is filed to get the medical expenses incurred to the complainant during the policy period. The case of complainant is that the complainant is a policyholder of respondent Company vide policy No. 100605/48/06/41/00000189. On 20.1.07 the complainant was admitted in Thrissur Heart Hospital due to severe pain in the right side of the stomach. She was treated there as inpatient from 20.1.07 to 23.1.07 as I.P.No.42964. After that she has applied for the policy benefits. But it was refused by the company.

 

            6. In the counter the respondent stated that the policy coverage is subject to the conditions stated in the policy. The main contention raised by them is that the claimant is not treated as an inpatient at any where as claimed in the petition. She has undergone some medical checkups in the Thrissur Heart Hospital from 20.1.07 to 23.1.07 as I.P.No.42964, but not undergone any treatment as inpatient. So the policy is inoperative due to these reasons and the complainant is not entitled for getting any amount.

 

            7. The reason for repudiating the claim stated by the respondent is the claimant is not treated as an inpatient. They stated that the complainant has undergone some medical checkups in the Thrissur Heart Hospital as I.P.No.42964 but not undergone any treatment as an inpatient. The complainant has produced Exts. P1 to P7 to prove her case. Ext. P5 is the discharge summary issued from Thrissur Heart Hospital. In that the admission date stated as 20.1.07 and the date of discharge stated as 23.1.07. So it is very clear that she was treated as inpatient in the said hospital. Ext. P6 is the copy of inpatient bill which comes Rs.3444.50. In the counter the respondent admitted that she has undergone some medical checkups in the Thrissur Heart Hospital as I.P No.42964. From which it is very clear that she was treated as inpatient. According to the respondent, some medical checkups were done during the inpatient period but not undergone any treatment as inpatient. This is a strange contention raised by the respondent without any document to support it. They further stated in the counter that the policy coverage is subject to the conditions stated in the policy. They did not even produce the details of policy. They depend only on the averments in the counter. No supporting evidence produced to establish their version. If such a policy condition is there they have to produce it and establish their case. The repudiation letter marked as Ext. R2 shows the reason as “as per submitted documents the treatment could have been taken as an outpatient due to which claim is repudiated”. The Company also produced discharge summary issued from the Thrissur Heart Hospital to the complainant. The discharge summary is a document issued to inpatients at the time of discharge. If she was treated as outpatient there would not any discharge summary. The room number in which she was admitted and the I.P. number were clearly mentioned in the discharge summary. This is a clear case where the respondent straightaway dishonoured a very clear genuine claim. So the complainant is entitled for compensation also.

 

            8. In the result, the complaint is allowed and the respondent is directed to pay the amount stated in Ext. P6 and Rs.5000/- (Rupees five thousand only) as compensation with cost Rs.1000/- (Rupees one thousand only) within a month.