Chandigarh Ombudsman Centre
Case No. GIC/128/NIC/11/07
H.C. Nair
Vs
National Insurance Co. Ltd.
Facts: HC Nair had taken a Mediclaim policy for sums insured of Rs. 50,000 for self and Rs. 20,000 for his wife for the period 30.9.05 to 29.9.06. He was admitted in Pushpanjali Hospital Delhi from 4.1.06 to 6.1.06. He has been a policyholder for the last six years and has never before lodged any claim. But the claim filed by him for hospitalization was repudiated on the ground that admission was for investigation purposes (policy clause 4.10). He sought intervention for reimbursement of claim amount.
Findings: The complainant stated that he felt pain in chest on 4.1.06 and had high BP. He collapsed in office and was taken by his colleagues to Singh Nursing Home where ECG was done which showed some abnormality. He was advised admission. He got himself admitted in Pushpanjali Medical Centre where he remained till 6.1.06. He had to undergo many tests. He admitted that no serious abnormality was detected, but initially it appeared that he had symptoms of heart ailment. The representative of the insurer stated that the hospitalization was primarily for investigation purposes, as the tests conducted did not reveal positive existence of any ailment. The investigations showed normal results.
Decision: Held that the claim is not payable as per exclusion clause 4.10. The case is accordingly closed.
