The court upheld the Ombudsman's decision, confirming that hospitalization for merely diagnostic purposes does not warrant insurance reimbursement.

J U D G M E N T

The petitioner who had availed an insurance policy from the respondent Insurance Company has filed the captioned Writ Petition seeking to challenge the findings contained in the award of the Insurance Ombudsman at Ext.P9, by which the claim preferred by the petitioner was rejected.

2. I have heard Smt.M.A.Sulfia, learned counsel appearing for the petitioner and Smt.Anna Johnson, learned counsel representing Sri.George A.Cherian, learned Standing Counsel for the respondent Insurance Company.

3. The petitioner was suffering from fever in July,2022.

On 29.07.2022, the petitioner was admitted in the Medical Trust Hospital, Ernakulam, as evidencd by the discharge certificate at Ext.P3. A persual of the certificate at Ext.P3 would show that the petitioner was admitted on 29.07.2022 due to "viral fever" and discharged on 01.08.2022. The discharge summary at Ext.P4 provides the details of treatment/procedures petitioner underwent during the period of hospital admission. A perusal of Ext.P4 would show that essentially, the petitioner had availed/was subjected to various tests during the period of hospital stay. It is with reference to the expenses incurred for the tests conducted as well as the stay at the hospital that the petitioner sought reimbursement with reference to the insurance policy availed by him.

4. The afore claim has been rejected by the insurance company by Ext.P6 essentially stating that the treatment stated to have been given to the petitioner herein "does not support the need for hospitalization". This stand of the Insurance Company was challenged before the Ombudsman and the Ombudsman by Ext.P9 found as follows:

“4. On perusal of the records, I note that while the Complainant was admitted citing complaint of fever and chills, after admission he did not have further fever spikes and was stable during the entire hospital stay. A whole series of investigations were then done at the hospital and all the investigations (scans, x-ray, Doppler Echo, blood tests including blood culture and Covid test) showed results that were within normal limits. There was no trace mark of fever or any other infection. Complainant being a known case of hypertension, hyperuricemia and Type II DM, a small increase in HBA1C reading was noted. I must therefore concede the RI's contention that these evaluations could have done as an OP procedure. The RI also has a clear case that there was practically no active line of treatment for any significant illnesses at the hospital and the medicines seen prescribed could have been done on OP basis too. It does appear reasonable for the RI to have considered that the admission to hospital was only to facilitate the tests that were done on the Complainant, not for treatment of any ailment that required hospitalization.”

It is the afore finding that is being challenged in this writ petition.

5. This Court notices, on a perusal of the insurance policy, copy of which has been produced along with the counter afÏdavit by the insurance company, as Ext.R1(a), that the clause with reference to the general exclusions specifically excludes "expenses related to any admission primarily for diagnostics and evaluation purposes". Therefore, the question of consideration is as to whether the treatment stated to have been availed by the petitioner, as evidenced by Ext.P4, was only for "diagnostics and evaluation purposes". A perusal of the discharge summary at Ext.P4 as well as the final award of the Ombudsman at Ext.P9 would show that during the period of hospitalisation, the petitioner was not having fever. The discharge summary at Ext.P4 states that the petitioner was admitted since he had episodes of fever. In such circumstances, I am of the opinion that the insurance company is jus