Group Mediclaim Policy - Gbic.co.in

insured under the maternity benefit extension cover of the policy and since the insurerhad already paid this amount, the complainant was not entitled to any further relief.The complaint was dismissed.Chennai Ombudsman CentreCase No. 11.5.1049 / 2005 - 06Shri R. GovindarajanVsThe Oriental Insurance Co. Ltd.Award Dated 22.8.2005The Complainant Shri R. Govindarajan was covered under the LIC Group MediclaimPolicy. He was hospitalised at Apollo Hospital from 27.10. 2003 to 29.10.2003 with thecomplaints of “pricking sensation over left Axillary region”. His claim for reimbursementof medical expenses was repudiated by the Insurer on the ground that thehospitalisation was for evaluation which is not covered under the policy as percondition No. 4.10. Shri Govindarajan represented to the Insurer for reconsideration ofhis claim on the grounds that all the tests done were on the advice of the reputedConsultant cardiologist, Dr. P. Ramachandran of Apollo Hospitals. He furthercontended that treatment has been given in the hospital after evaluation and he wasadvised further medication for the symptoms noted after admission, and had theevaluation indicated no treatment, the doctor would not have prescribed medicines.It was observed from the notings in the discharge summary that Shri Govindarajan hadcomplaints of breathlessness, chest pain, choking and pricking sensation in the leftaxilliary region which were significant enough for the attending doctor to suggestevaluation tests in the hospital. It was not that the insured was admitted in the hospitalfor a general health evaluation or did not have any health complaints at that point oftime. Complaints such as breathlessness and choking sensation in any person couldcause considerable anxiety and obviously, the attending doctor, in his wisdom, hadadvised for medical evaluation in order to assess the cause of the complaints. It wasalso noted that the complaints of pricking sensation, choking sensation, syncope etc.were not isolated incidents but have been afflicting the insured for 1 ½ months to 2months and hence were serious enough for the attending doctor to take cognizance forfurther detailed evaluation. The insured has symptomatically improved during his stayin the hospital and on discharge, he was prescribed a regime of medication related tocardiac problems as well as for the other complaints. The entire process of the insuredhaving presented with health complaints, diagnostic tests being conducted and theappropriate medication / treatment being prescribed, had taken place in the presentcase and hence the insurer’s contention that the hospitalisation was only for evaluationwas found not tenable and the insurer was directed to reimburse the admissiblemedical expenses to the complainant. The complaint was allowed.Delhi Ombudsman CentreCase No. GI / 512 / OIC / 04Shri Nandlal AroraVsOriental Insurance Co. Ltd.Award Dated 20.4.2005FACTS OF THE CASEThe complainant is a retired employee of LIC. The claim made by him is in respect ofthe hospitalization of his wife, Smt. Swarn Kumari, for treatment of a fracture in her leg