GALDAN WANCHUK Vs. FAMILY HEALTH PLAN LTD

JUDGEMENT

(1.) ORDER dated 19.2.2010 passed by the learned Divisional Forum Jammu (hereinafter to be referred as the Forum) has been taken in appeal, whereby and whereunder the complaint of the appellant has been dismissed; on the ground that the ailment from which the appellant was suffering had Insurance cover under the policy of Insurance to avail streatment, only, as an outdoor patient and not otherwise.

(2.) THE brief facts of the case are that Mr. Galdan Wanchuk had obtained medico claim Insurance Policy bearing No: 420806/48/03/ 8500962 which came into operation on 24.2.2005 and had to expire on 23.2.2006. The case of the appellant is that during the currency of the said policy, he developed the disease of major depression disorder with suicidal tendencies. For some time, he was examined in Government Medical College Hospital Jammu. Thereafter for the sake of availing specialized treatment, he was taken to "South Point Hospital, New Delhi". There, he remained as an indoor patient from 20.1.2005 to 4.2.2005. The appellant through his mother namely, Dr. P. Angmo raised the insurance claim. Respondent No. 1 being the third party Agent (TPA) authorized and licensed by IRDA vide their letter dated 23.2.2005 informed Dr. P. Angmo that as per the opinion received from their medical team the claim did not fall under the purview of policy for the reason, "the treatment could have been taken as an out -patient". The claim was for the reimbursement of Rs. 1,44,972 and the same was repudiated. After wards, the appellant got his medical treatment as an outdoor patient in Delhi from Dr. Sanjay Chugh and paid him the consultation fee and other charges (detailed in Annexure -C -colly Pages 39, 40, 41) on three occasions totalling Rs. 26,250. The claim was raised and respondent No. 2 and No. 3 got it processed through respondent No. 1. Respondent No. 1 informed Dr. P. Angmo vide letter dated 17.3.2005,"as per terms and conditions of Insurance Policy, OP treatment is not covered. Hence, the claim was repudiated." The signs of disease re -occurred and third time, the appellant was given the medical treatment in "SANTULAN" which is specialized centre for Management of psychiatric and Alcoholic/ Drug problem situated in Delhi. There he remained as an indoor patient from 3.11.2005 to 3.12.2005. The expenditure incurred for getting treatment was in the amount of Rs,. 65,100. This claim was also raised but was not paid; as it was also sent for getting Panel Report from the Approved Panel Doctors. On the record of the complaint file at page 79, there is Panel Report dated 23.3.2007 prepared by Dr. Sayed Manzhoor Sr. Medical Officer, Family Health Plan limited which says:

(3.) HEARD the arguments