Kochi Ombudsman Centre
Case No. IO/KCH/GI/21/2006-07
Sri. K.Sankaranarayana Pillai
Vs
Oriental Insurance Co. Ltd.
The complaint under Rule No.12 (1) (b) read with Rule 13 of the RPG Rules, 1998 relates to repudiation of a Mediclaim by the insurer. The complainant – a retired LIC official – had undergone angioplasty for Coronary problems in January 2000. Again, in July 2003 he was admitted in the same hospital (AIMS Kochi) for chest pain and related problems. The TPA of the insurer had taken a stand that the tests conducted in July 2003 were only for diagnostic purposes and hence was not payable. This view was also endorsed by the Insurance Company.
However, on evaluation of the records, it was found that the tests were for the purpose of continuous treatment in the background of the angioplasty done in 2000 and could not be therefore dismissed as diagnostic tests, which were not payable as per policy conditions. The insurer was also absent for the hearing before this Forum and they had not filed the circumstances of repudiation. Taking an overall view of the case, the contention of the insurer was found erroneous and hence the claim for Rs.11,777/- was ordered to be settled subject to compulsory deductions, if any.
