PER SHRI. S.B.DHUMAL - HON’BLE PRESIDENT :
1) In brief consumer dispute is as under –
That the Complainant was being an employee of M/s. DCM Shriram Consolidated Ltd. – unit Shriram Fertilizers and Chemicals. He was employed of M/s. DCM Shriram Consolidated Ltd. at 103, Arun Chambers, 80, Tardeo Road, Mumbai-34, from October, 92 to July, 08. The Complainant being an employee of M/s. DCM Shriram Consolidated was availing Group Mediclaim Insurance Policy issued by Opposite Party by making payment of necessary premium for him and for his family members for 16 continuous years.
2) During the period from 02/05/08 to 22/05/08, the Complainant’s mother Smt. Satyabhama Nambiar was diagnosed for the complaints of Moderate Osteoarthritis of both knees. Therefore, she took medical treatment at M/s. SBF Healthcare Pvt. Ltd. at Mumbai. According to the Complainant, his mother was treated for 21 days with Rotational Field Quantum Magnetic Resonance (RFQMR) a day care treatment which does not require hospitalization. X-rays of knees was taken. During the treatment of Complainant’s mother she was exposed to the radio-frequency beams one hour daily and was given physiotherapy. She was advised to take vitamins and follow certain diet restrictions. For aforesaid treatment the Complainant incurred expenses of Rs.87,763/-. The Complainant and his family members are insured under the aforesaid Group Mediclaim Policy issued by the Opposite Party during the relevant period of treatment. Therefore, Complainant preferred claim for reimbursement of medical expenses of Rs.87,763/- to the Opposite Party through his employer M/s. DCM Shriram Consolidated Ltd. – unit Shriram Fertilizers and Chemicals. Opposite Party vide their letter dtd.06/11/09 repudiated claim of the Complainant under Exclusion Clause 4.13 that ‘day care treatment’ is not allowed. The Complainant who was not satisfied with the decision made representation to the Opposite Party for re-consideration of his claim. After laps of considerable period, Opposite Party changed their earlier decision of rejection of claim stating that “We are closing your file on account of following reasons : Since day care treatment is not allowed. As per Exclusion Clause 4.13 Naturopathy, Unproven Procedure/treatment, experimental or alternative medicines/ treatment including Acupuncture, Acupressure, Magneto Therapy, etc.”
3) Being aggrieved by the aforesaid decision, the Complainant made complaint to Insurance Ombudsman and Insurance Ombudsman vide order dtd.16/10/2010, rejected the complaint. Therefore, the Complainant has filed this complaint before his Forum and requested to direct Opposite Party to pay to the Complainant an amount of Rs.87,763/- incurred for medical treatment alongwith interest @ 9 % p.a.. He has claimed compensation of Rs.1 Lac towards mental agony, cost of communication Rs.10,000/-, conveyance cost, legal charge and stationary, etc. total claim of the Complainant is of Rs.2,36,748/-.
4) Alongwith complaint, Complainant has produced copies of number of documents.
5) Opposite Party has filed written statement and thereby resisted claim of the Complainant contending that the complaint is misconceived and allegations made in the complaint are baseless and therefore complaint deserves to be dismissed with cost.
6) According to the Opposite Party, there is no deficiency in service on their part and they have not committed unfair trade practice. It is contended that complaint is barred by law of limitation. According to the Opposite Party, the Complainant had obtained Group Mediclaim Policy mentioned in the complaint from their Delhi Office. The Complainant has lodged the claim with their Delhi office which was repudiated by Delhi office therefore, this Forum has no jurisdiction to try and decide this complaint. It is submitted that Complainant’s claim is rightly repudiated as per terms and conditions of the Mediclaim Policy of Clause No.2.6 and Exclusion Clause 4.13. It is submitted that Complainant’s mother was treated with RFQUMR. The SBF Healthcare Pvt. Ltd. has issued certificate stating that it is day care treatment and does not require hospitalization. According to the Opposite Party, the basic criteria of hospitalization itself is not fulfilled as treatment was taken on daily sitting basis and therefore, the Complainant’s claim does not fall within the purview of the mediclaim policy. The Complainant filed complaint before the Insurance Ombudsman, Maharashtra and Goa, Mumbai which was dismissed on 08/06/2010. It is contended that Complainant accepted and agreed to the terms and conditions of the said policy as he has duly received policy alongwith terms and conditions. There is no deficiency in service on the part of Opposite Party and so complaint is liable to be dismissed.
7) It is submitted by Opposite Party that claim of Rs.2,36,748/- preferred by the Complainant is highly inflated and exaggerated and the Complainant is not entitle to any relief as prayed therefore, compliant be dismissed with cost.
8) The Complainant has filed rejoinder and thereby denied allegations made in the written statement. Alongwith rejoinder the Complainant has produced copies of number of documents. The Complainant has filed written argument. Opposite Party has also filed written argument. Heard oral submission of the Complainant and Ld.Advocate Mrs. S.S. Dwivedi for the Opposite Party and the complaint was closed for final order.
9) Following points arises for our consideration and our findings thereon are as under -
Point No.1 : Whether the Complainant has proved deficiency in service on the part of Opposite Party ?
Findings : Yes.
Point No.2 : Whether the Complainant is entitled to recover amount of claim alongwith interest, compensation and cost of this
proceeding as prayed in the complaintfrom the Opposite Party ?
Findings : As per final order.
Reasons :-
Point No.1 :- From the evidence on record it appears that the Complainant was an employee of M/s. DCM Shriram Consolidated Ltd. M/s. DCM Shriram Consolidated Ltd. has obtained Group Insurance Policy from the Opposite Party for its employees. The Complainant and his family members were covered under the said policy. The Complainant was serving at Division of M/s. DCM Shriram Consolidated Ltd., at 103, Arun Chamber, 80, Tardeo Road, Mumbai – 34 from October, 92 to July, 08 and during that period he and his family was covered under the aforesaid Group Insurance Policy. It is undisputed fact that the Complainant’s mother Smt. Satyabhama Nambiar was diagnosed for the complaints of Moderate Osteoarthritis of both knees and took medical treatment at M/s. SBF Healthcare Pvt. Ltd. at Mumbai. According to the Complainant, his mother was treated for 21 days with Rotational Field Quantum Magnetic Resonance (RFQMR) a day care treatment which does not require hospitalization. X-rays of knees were taken. During the treatment of Complainant’s mother was exposed to the radio-frequency beams one hour daily and was given physiotherapy. She was advised to take vitamins and follow certain diet restrictions. For aforesaid treatment the Complainant incurred expenses of Rs.87,763/-. Therefore, Complainant preferred claim for reimbursement of medical expenses of Rs.87,763/- to the Opposite Party through his employer M/s. DCM Shriram Consolidated Ltd. – unit Shriram Fertilizers and Chemicals alongwith letter dtd.08/09/09. The Opposite Party vide their letter dtd.06/11/09 repudiated claim of the Complainant on the ground under Exclusion Clause 4.13 that ‘day care treatment’ is not allowed. After laps of considerable period, Opposite Party changed their earlier decision of rejection of claim stating that “We are closing your file on account of following reasons : Since day care treatment is not allowed. As per Exclusion Clause 4.13 Naturopathy, Unproven Procedure/treatment, experimental or alternative medicines/ treatment including Acupuncture, Acupressure, Magneto Therapy, etc. is not allowed and so the Complainant’s claim is treated as ‘No Claim’.”
The Complainant has produced certificate issued by SBF Healthcare Pvt. Ltd. regarding FRQMR treatment given to Mrs. Satyabhama Nambiar.
It appears from the evidence on record that M/s. DCM Shriram Consolidated Ltd. has obtained Group Mediclaim Policy for its employee and the Complainant being employee’s availed insurance cover for about 18 years. During the period from October, 92 to July, 08, the Complainant serving at Tardeo Road, Mumbai in Divisional office of M/s. DCM Shriram Consolidated Ltd. During aforesaid period the Complainant’s mother Mrs. Satyabhama Nambiar received complaint of pain in knee, received RFQMR treatment from M/s. SBF Healthcare Pvt. Ltd., Mumbai from 02/05/08 – 22/05/08.
According to the Opposite Party Mediclaim Insurance Policy alongwith its terms and conditions was given to the Complainant and the Complainant accepted the terms and conditions of the said policy. If the Complainant had any grievance regarding the terms and conditions, he would have to informed the Opposite Party at the time of inception of policy. Mediclaim Policy in question is a Group Insurance Policy. It was obtained by M/s. DCM Shriram Consolidated Ltd. from the Opposite Party for its employees. There is nothing on record to show that the Opposite Party had given terms and conditions of the said policy to the Complainant therefore, we do not find substance in the contention raised by the Opposite Party that the Complainant accepted terms and conditions of policy. The Complainant’s mother received medical treatment at Mumbai. Opposite Party communicated its decision of repudiation of claim to the Insured M/s. DCM Shriram Consolidated Ltd. From time to time towards Mediclaim policy premium was deducted or collected from the Complainant while he was serving at Bombay. After rejection of claim of the Complainant, the Complainant has preferred complaint to the Insurance Ombudsman to the Maharashtra and Goa. Copy of the award dtd.08/02/2010 passed by the Insurance Ombudsman, Maharashtra and Goa is annexed in the complaint. It appears from the award that Opposite Party had not challenged jurisdiction of Insurance Ombudsman, Maharashtra and Goa. Opposite Party has its Regional Office at Churchgate, Mumbai. There is no substance in the contention raised by Opposite Party that cause of action or part of cause of action has not taken place within territorial jurisdiction of this Forum.
The Complainant has submitted that RFQMR treatment is new technology that is made to deliver highly complex quantum EM (non thermal) beams. These beams are delivered in the sub-radio and near radio frequency pattern. It is non-invasive, painless and safe treatment. Clinical trials are conducted over 400 cases of Osteoarthritis. The findings are published in the Journal of Aerospace Medicine. It involves the application of electromagnetic beams to regenerate tissues that wear and tear due to the ageing. It is submitted that this treatment is approved by State of Punjab for its employees. Oriental Insurance Company Ltd., Bajaj Alliance, TTK Healthcare Insurance have reimbursed the claims for RFQMR Therapy. The treatment is less expensive. However, Opposite Party has wrongly rejected reimbursement of misinterpreting Clause No.2.6 and Exclusion Clause 4.13 of the Mediclaim Policy.
Ld.Advocate for the Opposite Party has justified decision of repudiation of claim relying upon Clause No.2.6 and Exclusion Clause 4.13 of the policy. Opposite Party has recited Clause No.2.6 of the policy which is as under –
“Expenses of hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specify treatments i.e. Dialysis, Parentral Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (Kidney Stone removal), D & C, Tonsillectomy, Dental Surgery due to Bladder, Pancreas & Bile duct, surgery of Hernia, Surgery of Hydrocele, Surgery of Prostate, Gastrointestinal surgery, genital Surgery, Surgery of Nose, Surgery of Throat, Surgery of Appendix, Surgery of Urinary System, Arthroscopic Knee Surgery, Laparoscopic Therapeutic Surgeries, Any surgery under Anaesthesia, Treatment of Fractures/Dislocation excluding hairline fracture, Contracture releases & minor reconstructive procedures of limbs which otherwise require hospitalization taken in the Hospital/Nursing Home under the network of TPA and the Insured is discharged on the same day. The treatment will be considered under Hospitalization Benefit.”
Opposite Party has not recited relaxation of 24 hours minimum duration for hospitalization stated in Clause 2.6A and B which are as under –
A)If they are carried out in day care centre networked by TPA where requirement of minimum number of beds are overlooked but it must have
(a) Fully equipped Operation Theatre (b) Fully qualified Day car staff
(c) Fully qualified Surgeons/Post Operative attending Doctors.
B) If it necessitates hospitalization & involves specialized infrastructural acilities available only in hospital but due to technological advancement hospitalization is required for less than 24 hours and/or the surgical procedure involved has to be done under General anaesthesia.
Opposite Party has also recited Exclusion Clause No.4.13 as under –
“Naturopathy, unproven procedure/treatment, experimental or alternative medicine/treatment including acupuncture, acupressure, magneto-therapy, etc.”
As discussed above “RFQMR” treatment is advanced treatment in which hospitalization is not required relaxation of 24 hours minimum duration of hospitalization is given in Clause No.2.6. Such treatment is carried out at M/s. SBF Healthcare Centre which is fully equipped. Due to technological advancement hospitalization is required for less than 24 hours. Opposite Party has not stated relaxation of minimum 24 hours during hospital under the Clause No.2.6. In their written statement as per Clause No.4.13 Naturopathy, unproven procedure/treatment, experimental or alternative medicine/treatment including acupuncture, acupressure, magneto-therapy, etc. are excluded. It appears from the medical literature produced by the Complainant that RFQMR treatment is not Naturopathy and unproven treatment or experimental treatment. It is now widely used and recognized. The State Government of Punjab has recommended RFQMR for its employees. From the evidence on record it appears the claims for RFQMR are sanctioned by Bajaj Alliance, Oriental Insurance and some TPA. Considering evidence on record, it appears that repudiation of the Complainant’s claim for reimbursement of treatment of RFQMR of Complainant’s mother is not justifiable. Rejection of claim on such ground amounts to deficiency in service on the part of Opposite Party. Therefore, we answer point no.1 in the affirmative.
Point No.2 : The Complainant has submitted claim form for reimbursement of medical treatment of Rs.86,763/- which is wrongly rejected by the Opposite Party. Therefore, we think it just to direct Opposite Parties to pay to the Complainant an amount of Rs.86,763/-.
The Complainant has claimed interest @ 9 % p.a. on the aforesaid amount. The Opposite Party has wrongly rejected claim of the Complainant. There was delay on the part of Opposite Party in taking decision regarding the claim of the Complainant. Therefore, we think it just to direct Opposite Parties to pay to the Complainant interest @ 9 % p.a. from 08/09/09 till realization of entire amount to the Complainant.
The Complainant has claimed Rs.1,00,00/- as compensation for mental agony and Rs.8,000/- towards application cost, Rs.10,000/- as cost of communication, Rs.7,500/- as conveyance cost, Rs.5,000/- cost of consolidation and Rs.1,000/- as stationery and photographs. The Complainant’s claim for compensation and mental agony is exorbitant. The Complainant has not produced evidence to prove that he has incurred Rs.10,000/- towards cost of communication, Rs.7,500/- as conveyance cost, Rs.5,000/- as consolidation charges, etc. Considering facts and circumstances of the case, we think it just to direct Opposite Party to pay to the Complainant Rs.5,000/- for mental agony and Rs.2,000/- as cost of this proceeding. Rest of the Complainant’s claim is rejected. Hence, we answer point no.2 accordingly.
For the reasons discussed above, we pass the following order -
O R D E R
i.Complaint No.231/2010 is partly allowed.
ii.Opposite Party No.1 to 4 shall jointly and/or severally pay to the Complainant an amount of Rs.86,763/-
(Rs. Eighty Six Thousand Seven Hundred Sixty Three Only) towards reimbursement of medical expenses
with interest @ 9 % p.a. on aforesaid amount from 08/09/2009 till realization of entire amount to the
Complainant.
iii.Opposite Party No.1 to 4 shall jointly and/or severally pay to the Complainant an amount of Rs.5,000/-(Rs.
Five Thousand Only) towards compensation for mental agony and Rs.2,000/- (Rs. Two Thousand Only)
towards cost of this proceeding to the Complainant.
iv.Opposite Party No.1 to 4 shall jointly and/or severally comply with the aforesaid order within period of one
month from the date of receipt of this order.
v. Certified copies of this order be furnished to the parties.
