Mumbai Ombudsman Centre
Complaint No. GI-268 of 2005-2006
Shri Rajnikant Ravilal Doshi
V/s
Oriental Insurance Company Limited
Shri Rajnikant Ravilal Doshi was covered under the Mediclaim policy issued by The Oriental Insurance Company Limited, D.O. 4 since 1988-89. When Shri Rajnikant Doshi preferred a claim for the said hospitalisation to The Oriental Insurance Company, the third party administrator of the Company M/s Raksha TPA repudiated the claim invoking clause 4.1 of the mediclaim policy. Not satisfied with the decision of the Company, Shri Doshi represented to Oriental for reconsideration of his claim but the Company based on their panel doctor’s opinion reiterated the stand taken by their TPA in repudiating the claim.
In absence of the confirmation of the policy records the only course open to the Forum is to go by at least the Income-Tax records produced by Shri Doshi valid for the period 1991-92. On the grounds of lack of proof and confirmation by the Company to convincingly establish that the Insured was not covered under their earlier policy and considering the fact that the Insured was continuously insured with the same Company for atleast 13 years, the forum decided that the insured should get the benefit of doubt with only 50% payment of admissible hospital expenses as a special case.
Order: The Oriental Insurance Company Limited is hereby directed to settle the claim of Shri Rajnikant R Doshi for the expenses incurred by him for his hospitalisation at P.D.Hinduja Hospital from 5.9.2004 to 10.9.2004 for Superior Sagittal sinus thrombosis c venous infarct Rt. Parietal region and pay only 50% of the admissible expenses. There is no order for further relief. The case is disposed of accordingly.
