Oriental Insurance Co. Ltd. vs P.S. NARAYANA RAJA

THE complainant paid a premium of Rs. 5,264 and went for a mediclaim insurance cover for the period from 27.4.1997 to 27.4.1998. During the period he developed heart attack and was admitted in the Ramchandra Hospital, Chennai where he underwent treatment for twenty days. He again suffered anterior wall infarction for which he was admitted to the same hospital and underwent a coronary orthery by-pass graft surgery on 3.6.1997. THE complainant incurred a total expenditure of Rs. 1,51,835.75 p. THE complainant made a claim to the opposite party. THE opposite party did not respond. Hence the complaint.

IN the objection filed by the opposite party, they contended that it is true that the complainant sought cover under mediclaim insurance policy. But the liability is subject to the terms and conditions and exclusions incorporated in the policy. The opposite party engaged the services of a private investigator and came to know that the complainant was admitted in the hospital as in-patient till his discharge on 12.6.1997 after the surgery. Since a claim in respect of treatment for an ailment within 30 days of insurance could not be made under the policy, the complainant had made it to appear that he was admitted only on 30.5.1997 and has managed to secure two separate bills from the hospital authorities and thus suppressed the fact that he was in treatment from 5.5.1997. The complainant was aware of the need for surgery even earlier. The contention of the complainant that a claim was not for the hospitalization on 5.5.1997 but for the second hospitalization which occurred beyond 30 days from the date of insurance cover is wholly untenable. The claim fell within the exclusion clause in the policy. The opposite party applied its mind and arrived at the just conclusion not to entertain the claim. There is no deficiency in service. The Lower Forum accepted the complainant''s version and directed the opposite party to pay a sum of Rs. 1,51,835.75 p. with interest thereon along with a sum of Rs. 17,000 i.e., Rs. 5,000 towards mental agony, Rs. 5,000 towards deficiency in service, Rs. 5,000 towards delay in settling the claim and Rs. 2,000 towards costs. The exclusion under Clause 4 of the policy specifically provides that "any expenses of hospitalization/domiciliary hospitalisation incurred during first 30 days from the date of commencement of insurance cover except in case of injury arising out of accident." Therefore, from a reading of the exclusion clause, it is obvious that the opposite party cannot be made liable if the expenses of hospitalization had been incurred during the first 30 days from the date of commencement of the insurance cover. The insurance cover was from 28.4.1997 to 27.4.1998. The complainant admits that he was admitted in the Ramachandra Hospital on 5.5.1997. According to him, he was discharged after 20 days and that he is not making claim in respect of the said hospitalization. His case is that he had anterior wall infarction on 28.5.1997 for which he was admitted in the hospital on 30.5.1997 and for which the surgery was performed on 3.6.1997 and he was discharged from the hospital on 12.6.1997. In respect of this, he claims to have spent a sum of Rs. 1,51,835.75 p. for which the present claim is made.

The opposite party would contend that he was admitted no doubt in the hospital on 5.5.1997 for which alone he underwent the necessary treatment. His claim is that he was again admitted on 28.5.1997 is not correct. He continued to be in the hospital as in-patient and was discharged finally only on 12.6.1997. The complainant has produced the bill summary which is of no use. He has produced a discharge summary which gives the date of discharge as 12.6.1997. There is no column here mentioning the date of admission. The bills submitted by the complainant are found in two parts. It is to be pointed out that he was admitted in the hospital on 5.5.1997 where some tests were done and treatment was given for about 20 days. The other part of the bill shows that he was admitted in the hospital again on 30.5.1997 and later was operated upon. It is not in controversy that the ailment for which he was earlier admitted and discharged, the ailment for which he was later admitted and was operated upon were not different but the same one viz., cardiac problem. The opposite party/appellant would rely upon the investigator''s report to show that with the connivance of the hospital authorities it was made to appear that the complainant again got himself admitted on the 30th to enable him to make a claim. Though such a contention has been raised, there must be some material for us to arrive at such a conclusion. The mere juxtaposition of date cannot alone lend strength to such a case. The hospital authorities have issued two separate sets of bills for two spells. There is nothing in the report of the investigators to show that they examined the Doctor concerned. Therefore, as the records stand, there is no basis for us to conclude just on the ipse dixit of the investigator to hold that he was admitted on 6.5.1997 and was discharged on 5.6.1997. It is possible that when he was originally admitted, perhaps for some reasons, it was not thought fit or suitable to carry out the operation immediately or that he again felt some discomfort and hence he was admitted in the hospital after a couple of days when the operation was performed. Therefore, in such circumstances, in the absence of any material to suggest a strong link and continuity, we are unable to find acceptance to the case of the opposite party.

NOW, coming to the quantification, the complainant has produced material to show that he has spent a sum of Rs. 1,51,835.75 p. which amount he is entitled to claim and recover from the opposite party. The grant of another sum of Rs. 17,000 is, in our opinion, not warranted. In short, we have to hold that the complainant will be entitled only to an interest at 9% on the sum from the date of the complaint. In the result, we confirm the order passed by the Lower Forum. We modify the award passed by the Lower Forum holding that the complainant is entitled to a sum of Rs. 1,51,835.75 p with interest at 9% from the date of complaint till payment. Appeal disposed of.