Condition of the Complainant did not warrant hospitalisation : Insurance Claim Dismissed by Ombudsman

The condition of the Complainant at the time of admission in the Hospital was such as not to warrant hospitalisation. Repudiation of claim by Newindia upheld by Insurance Ombudsman, Ahmedabad

 

Ahmedabad Ombudsman Centre
Case No. NIA / 1 / 300

Mr. K. N. Prajapati
Vs.
The New India Assurance Co. Ltd.

Award Dated 04.10.2004

Complainant got admitted in a Hospital from 30.09.02 to 03.10.02 under the care of Dr.Doshi. Respondent repudiated the claim based on the opinion of their MR Dr. V. C. Parikhthat the Complainant had Malarial Parasites 7 days before his hospitalisation because, the Pathological test done one 28.09.2002 did not show any blood parasites, and further that either Consulting Doctor or Treating Doctor had advised the Insurer for hospitalisation. 

It was the Complainant’s argument that he consulted Dr. Doshi on 24.09.02, and Dr. Doshi diagnosed it as malaria Fever and under medical advice, urine and blood test were conducted. Documents perused. It is observed that the Complainant had consulted three more Doctors before consulting Dr. Doshi, and except Dr. Doshi, all other Doctors had prescribed medicines and recommended pathological tests. 

The pathological test conducted on 28.09.2002 did not show any Blood Parasite. It is also observed from the Discharge Card of Dr. Doshi’s Hospital that the past history of the patient has noted as “No history of major illness, no fever, head – ache for 3 days, vomiting twice, giddiness”.

Further, no document could be found to establish that the hospitalisation was under advice of any Doctors and hence, the condition of the Complainant at the time of admission in the Hospital was such as not to warrant hospitalisation. Repudiation upheld.