ORDER

Per SH. RAKESH KAPOOR, PRESIDENT



   The complainant is holder of a mediclaim policy issued by the OP .
The policy was valid for the period 29.12.2013 to 28.12.2014. It has
been alleged by the complainant that on 14.3.2014 his wife (one of the
beneficiaries under the policy ) was hospitalized for treatment of
localized tenderness in her right leg.  He had spent a sum of Rs.
45,670/- on the said treatment and had lodged a claim with  the OP.
The OP had repudiated the claim vide letter dated 3.7.2014  on the
plea that the claim was not admissible under clause 4.11 of the policy
of insurance purchasd by the complainant.   The complainnt has alleged
that this act of the OP was uncalled for and amounts to deficiency in
service and has, therefore, approached this forum with the present
complaint.

            The OP has  contested the complaint and has filed a
written statement. It has denied any deficiency in service on its
partand has claimed that the complaint has no merits and is liable to
be dismissed.   It has , however, admitted that a mediclaim policy was
issued by it in favour of the compainant as alleged in the complaint .
It has justified its action of repudiation of the claim  and has
prayed for the dismissal of the complaint.

            We have heard arguments advanced at the bar and have
perused the record.

    The claim lodged by the complainant has been repudiated by the OP
vide letter dated 3.7.2014 which inter-alia  reads as under:-



 You preferred the mediclaim for reimbursement of your spouse Mrs.
Anjum. The TPA MD ,india has turned down the clam keeping in view the
condition no. 4.11 of the policy as under (exclusions)



“charges incurred at hospital or nursing primarily for diagnosis,
x-ray or laboratory examination or other diagnosis studies not
consistent with or incidental to the diagnosis and treatment of
positive existence or presence of any ailment, sickness or injury for
which the  confinement is required at a hospital/ nursing home.”



Keeping in view of the above, the claim has been turn down, the
treatment taken does not warrant for hospitalization, which can be
taken as OPD, hence not payable under mediclaim policy. We are sorry
for the inconvience casued to you.

Therefore, the claim has been repudiated on the ground that the
admission im hospital was primarily for the purposes of diagnosis and
that the treatment could  have been taken as an OPD patient.  The
complainant has placed on the file the treatment record which shows
that the wife of the complainant was admitted in the hospital with
the chief complaint of local back /leg pain right side mainly while
standing/ walking. she was administered several medicines for her
condition and was duly treated for the condition for which she was
admitted in the hospital. There is nothing on the record to show that
the patient was hospitalzed simply for evaluation/ diagnosis. Even
otherwise, the patient was advised admission in the hospital by a
qualified doctor and had no option but to act accordingly.

            We are , therefore, of the considered opinion that in the
facts and circumstances of the case , the OP insurance company ought
not to have repudiated the claim lodged by the complainant.  We hold
the OP insurance company guilty of deficiency in service and direct it
as under:-



1.    Pay to the complainant  a sum of Rs 45670/- along with interest
@ 10% p.a. from the date of institution of this complaint i.e.
6.8.2014  till payment.

2.    Pay to the complainant a sum of Rs 10,000/-a s compensation for
the pain and agony suffered by him..

3.    Pay to the complainant a sum of Rs. 5,000/- as cost of litigation.

       The OP shall pay this amount within a period of 30 days from
the date of this order failing which they shall be liable to pay
interest on the entire awarded amount @ 10% per annum.  IF the OP
fails to comply with this order, the complainant may approach this
Forum for execution of the order under Section 25/27 of the Consumer
Protection Act.





Copy of the order be made available to the parties as per rule.

    File be consigned to record room.

          Announced in open sitting of the Forum on.....................