Chandigarh Ombudsman Centre
Case No. GIC/119/NIC/14/07
Sushiksha Mitra
Vs
National Insurance Co. Ltd.
Facts: Susiksha Mitra had taken a mediclaim policy from BO Gurgaon. She was hospitalized for a day on 18.1.06. She submitted the claim for Rs. 7000. Since the claim was not settled, she filed a complaint seeking intervention.
Findings: The insurer sought justification for hospitalization. As there was no response from the complainant, the claim was treated as ‘no claim’. The file was sent to the panel Dr. Sharad Mathur for opinion. He expressed the view that there was no need for hospitalization as the patient is a known case of Atrial Fibrillation and Hypertension as per discharge summary and she was admitted for readjustment of continuing medication only. At the time of admission, there was no emergency. The cause of hypertension could have been evaluated by ECG only.
Decision: It is not disputed that insured had past history of some ailments and during the course of investigations some changes were detected. The basic question involved in this case is whether hospitalization was required or not. The categorical view of the panel doctor is that this was not required as investigations were undertaken for readjustment of continuing medication only, which was possible on OPD basis. The plea of the complainant is that hospitalization was on the advice of a treating doctor. However, keeping in view the past history and the degree of severity of the problem, hospitalization was not warranted.
