Passed by Shri Atul D. Alsi, Hon’ble President.

1. The complainant has filed complaint case against repudiation of insurance claim for medical hospitalisation charges and medical expenses of Rs.35,000/-along with interest and compensation against the arbitrary rejection of claim.

The story in short is as under,

2. The complaints is Civil contractor and insured himself under insurance policy of O.P.-Religare Health Insurance prospectus along with his family members for the health treatment of any kind of disease and hospitalisation along with various tests charges vide policy no.-11935777 for the period between 10.1.2018 to 9.1.2019.
3. On dated 15.7.2018 the complainant was ill health due to fever and headache and after consultation with doctor he was hospitalised at Green Care Nursing Home, Nagpur on 16.7.2018. After various necessary tests the complainant diagnosis as Typhoid, headache and dehydration.  Thereafter, after treatment the complainant was discharged on 19.4.2018 at evening and advice rest.
4. The complainant filed insurance claim through agent Mr. Mohan Badwik for medical expenses with relevant bills on 17.8.018 for reimbursement of Rs.35,000/- but the claim was rejected holding that the diagnosis or treatment or tests do not required hospitalisation.  The conduct of O.P. was unpredictable and committing Unfair Trade Practice with intention to avoid liability there for present complaint is filed.
5. The O.P. filed reply and denied allegation. But admitted the insurance policy of the complainant bearing No.11935777 where the compliant and his family member were covered for total sum insured of Rs.3,00,000- (Three lac ) subject to terms and condition of policy. The complainants insurance was denied observing that for investigation and evaluation is not covered under the policy benefit under 4.1(1) read annuxure2 (71) and insured could have managed on OPD basis all reports and vitals are almost WNL as per provided ICP could be managed on OPD basis, permanent exclusion any diagnosis or treatment of illness or injury which does not required hospitalisation. The final bill submitted by the complaint along claim form it can be observed most of the expenses charged by hospital was only for bed charges and Doctor Charges. As per discharge summery under the head treatment given it has mentioned that the complainant management was done IV Fluids antibiotics and other supportive medication. Therefore no hospital was required and insured could have been managed on OPD basis.  On perusal of investigation reports it clearly suggested that no active diseases diagnosis therefore rejection of insurance claim for exclusion clause 4.2  of the policy does not amount to Unfair Trade Practice.

Reasoning

6. The complainant’s insurance claim for hospitalisation and medical expense filed under the policy bearing No.11935777 was rejected for the reason of permanent exclusion clause 4.2 of the policy, during investigation the complainant had undergone test included KFT/CBC, other routine tests which could be managed on OPD basis. The treatment given during hospitalisation is antibiotics medicine and other supportive medication there it clear establishes that there was no requirement of indoor patient for treatment and as per terms and policy of the insurance claim is payable incase of hospitalisation and treatment to that effect. Therefore rejection of insurance claim for the reason of *clause No.4.2 permanent exclusion of terms and condition of policy does not amount to Unfair Trade Practice on the part of O.P.  Therefore compliant is dismissed as per following order.
6698606.  

1. Complaint is dismissed.
2. No order as to costs.

Copy of order be furnished to both the parties, free of cost.