J U D G E M E N T         

              The door of this Forum has been knocked by the Complainant, for redressal arising out of the consumer dispute as per the Consumer Protection Act, 1986.

              In laconic, the case stated in the complaint, is that, the Complainant had obtained a Medi Claim Policy under the Opposite Party No. 1, vide Policy No. 512503/34/10/11/00000370 since 30.07.2004 and the said Policy was/is duly renewed time to time by paying the due premium to the Opposite Parties. Suddenly from the last week of the May, 2010, the wife of the Complainant was attacked by severe ‘Knee Pain’  and was treated by different Orthopedic Specialist Doctors as well as by Orthopedic Surgeons who opined the said disease as ‘Osteoarthritis’ . But due to no improvement in her Knee Pain ultimately the Complainant took her to the eminent Doctors of the Vellore Hospital at Bangalore/ Chennai and before going there the Complainant had duly informed the matter to the Opposite party No. 2 on 17.06.2010 and had been informed the opposite Parties time to time. 

             At the Vellore Hospital, the wife of the Complainant was treated by QMR  Therapy (Quantum Magnetic Resonance Therapy), a specialist procedure of Advancement in Medical Technology which is painless, safe, non–invasive and cost effective alternative method of treatment when compared to surgery to help regenerate cartilage and restore Mobility of Arthritic Knee Joints which is considered safe for human use, from the period of 04.08.2010 to 24.08.2010 and got recovered from such severe Knee Pain. Thereafter the Complainant had submitted the claim of Rs. 1,10,785/- only which was the actual expenses incurred by the Complainant for the said QMR Therapy treatment before the Opposite Party No. 1 in prescribed form along with all relevant documents on 13.10.2010 in respect to the said Policy. But after lapse of 9 months the Opposite Parties had repudiated the said claim by sending a letter dated 14.06.2011 on the reason that as per directive from parent Insurance Company the QMR Therapy is not payable. Hence the claim is repudiated.

                The Complainant preferred an appeal before the Opposite parties to reconsider the claim of the Complainant as prior to the treatment the information regarding such treatment was properly communicated to the Opposite Parties Insurance Company but the prayer of reconsideration was whimsically and deliberately rejected by the Opposite Parties with an ulterior motive. The Opposite Party Insurance Company had intimated by sending a letter to the Complainant that the said QMR therapy was /is an experimental and unproven treatment and not recognized by Indian Medical Council. But the Complainant alleged that some other persons previously realized the claim for such identical treatment by this Opposite Party Insurance Company and General Insurance Company and United India Insurance Company. But this Opposite Parties Insurance Company did not paid any heed to the request of the Complainant and had repudiated the said claim of the Complainant, what amounts deficiency and/or negligence in rendering service towards him, for which he has to suffer harassment and mental agony and prayed for compensation. Hence, this case is filed seeking adequate redressal.

               Resisting the complaint, the Opposite Parties filed the Written Version denying each and every allegation made by the Complainant in the petition of complaint contending inter alia, that the Complainant has no cause of action and is not maintainable either in fact or in law.

               The specific case of the Opposite Parties, in terse, is that, the Opposite Party Insurance Company denied the fact that the Complainant intimated the decision of getting treatment of QMR Therapy of the patient from the SBF Health Care Pvt. Ltd. in which event the Complainant would be intimated that thye cost of such treatment would never be reimbursable under the MediClaim Policy and no approval of the Opposite parties was ever taken prior to the treatment and so the Opposite parties is under no obligation to settle the said claim.

                Moreover as per the Policy as the claim of Rs. 1,10,785/- only was not settle worthy the claim could not be settled as the terms of the Policy is that the treatment expenses incurred for Ayurvedic/Homiopathic/ Unani Treatment is not covered under the Medi Claim Policy.

            Thus the Opposite Parties never intended to deceit the Complainant by any means, therefore there was no negligence or deficiency on part of the Opposite Party in rendering the service towards the complainant. Thus, the Opposite Parties prayed for dismissal of the case.

                           Points for Consideration

   1. Is the complaint maintainable under the C. P. Act ?

   2. Was there any negligence or deficiency in service

                        on the part of the O.P ?                            

   3. Is the complainant entitled to get the relief as prayed for ?

                                         Decision with reasons

               All the points are taken up together for consideration for convenience and brevity.

               The main dispute between the Complainant and the Opposite Party is that whether the Complainant is entitled to get the claim and the Opposite Parties Insurance Company is liable to disburse the said claim amount of the treatment of her wife in favour of the Complainant or not.

                In coming into conclusion regarding the present dispute we have gone through the Complaint and Written Version and also critically appreciated the material documents on record and we have gathered that admittedly Complainant is a consumer under the Opposite Parties by obtaining the Medi Claim Policy.

              On overall evaluation of the argument advanced by the Ld. Advocate for the Complainant and of the argument advanced by the Ld. Advocate for the Opposite Party No. 1 and 2 and on critical appreciation of the case record, it is clearly evident that admittedly the Complainant had obtained a Medi Claim Policy under the Opposite Party No. 1, vide Policy No. 512503/34/10/11/00000370, since 30.07.2004 and the said Policy was/is duly renewed time to time by paying the due premium to the Opposite Parties and was still in force at the time of submitting the said claim.

              Admittedly the fact remains that suddenly from the last week of the May, 2010, the wife of the Complainant was attacked by severe ‘Knee Pain’  and was treated by different Orthopedic Specialist Doctors as well as by Orthopedic Surgeons who opined the said disease as ‘Osteoarthritis’ . But due to no improvement in her Knee Pain ultimately the Complainant took her to the eminent Doctors of the Vellore Hospital at Bangalore/ Chennai where the wife of the Complainant was treated by QMR  Therapy (Quantum Magnetic Resonance Therapy) from the period 04.08.2010 to 24.08.2010 and got recovered from such severe Knee Pain and to do the said treatment admittedly the Complainant has to spent a sum of Rs. 1,10,785/- only at the said Vellore Hospital.

              After returning the Complainant had duly submitted the claim of Rs. 1,10,785/- only (the entire treatment cost) before the Opposite Party No. 1 in prescribed form on 13.10.2010 along with all relevant documents regarding the treatment in respect to said Policy.

                  The record reveals from the photocopies of the documents filed by the Complainant that after lapse of 9 months the Opposite Parties had repudiated the said claim by sending a letter dated 14.06.2011 with remarks ‘No Claim’ in nature and thus not payable under the rules guiding the policy on the reason that : as per directive from parent Insurance Company the QMR Therapy is not payable. Hence the claim is repudiated.

               It is revealed from the record that the Opposite Parties has admitted the fact by filing the Written Version that they had repudiated the claim of the Complainant on the said ground and counter alleged that the Complainant knowing fully well that the treatment under QMR Therapy is not come under the Insurance Policy had been treated his wife by this QMR therapy.

              At the time of hearing argument the Ld. Advocate for both the Opposite Parties argued and noticed in the terms and conditions of the Insurance Policy and drew the attention of the Forum wherein the Clause 2.7 of the said terms and conditions it is evident that the treatment expenses incurred for Ayurvedic/Homiopathic/Unani Treatment are admissible upto 25 % of the sum insured provided the treatment for illness / disease and accidental injuries is taken in the registered hospitals which are qualifying the definitions of hospitals excluding centres for spa, massage and health rejuvenation procedures under the Medi Claim Policy.  

              But the Ld. Advocate for the Opposite Parties specifically submitted that the said QMR Therapy is not the treatment under the Ayurvedic or Homiopathic  or  Unani  and  so the amount incurred for the treatment for doing the QMR treatment was/is not payable by the Opposite Party Insurance company.

                On the other hand the Ld. Advocate for the Complainant stated and submitted that before the said treatment would be stared the Complainant verbally seek the permission of the officials of the Opposite Party No. 2 which was denied by the Opposite Party No. 2.

             Now the only question is that whether the treatment under the QMR therapy is the recognized therapy under the medical treatment or not and whether the Opposite Party Insurance company is liable to reimburse/pay the actual expenses incurred for the said treatment upto the limit of that extend to that amount insured by the bonafide Insured/Consumer (in this case the Complainant) to the Complainant/ any other Insured or not.

              But the Opposite Party never filed any document and/or any scrap of paper from which it would be evident that the QMR Therapy is not payable by the Insurance company and moreover no guideline and/or directives from any appropriate authority even not any directives and/or circular or any other guidelines from the part of the IRDA that the said QMR Therapy is not a recognized treatment and the claim of the Insured who has been undergone through this treatment  is not payable by the Insurance company. Moreover nowhere from the terms and conditions of the said Insurance Policy which has specifically been noticed by the Ld. Advocate of the Opposite Party it is found that this QMR Therapy is excluded and the insured is not entitled to get the claim who undergone this treatment.

             On the other hand the Complainant filed all the treatment documents/papers which shows that the Complainant was duly advised by the MBBS Doctor (Consultant Orthopedic Surgeon, named Dr. Shuaib Kausar) for this QMR Therapy for 21 days consecutivel             Manifestly the record reveals from the photocopies of the documents filed by the Complainant that the wife of the Complainant (the patient) was treated at the SBF Healthcare Pvt. Ltd.  and she was treated therein from the period of 04.08.2010 to 24.08.2010 under observation of the authorised treating doctor. The Complainant also filed all the ‘Treatment Sheets’ / ‘Prescriptions’ and other relevant documents/papers relating to this treatment under QMR Therapy in this regard which clearly shows that the said QMR Therapy treatment had actually been done in the said Hospital.

              It is further revealed from the photocopies of the documents filed by the Complainant that the Complainant had actually incurred the expenses of Rs. 1,10,785/- only for the QMR Therapy treatment of her knee which the Complainant has submitted the  claim along with all relevant documents/papers before the Opposite Party No. 1 and the such claim was submitted before the Opposite Party within the due time.

              The Ld. Advocate of the Complainant filed/submitted/produced a ruling of the Hon’ble National Commission (an Order dated 23 Feb 2015 passed by the Hon’ble National Commission in Appeal No. 234/2014 out of the Order passed by the Hon’ble State Commission, Karnatak) wherein the Hon’ble Bench of the National Commission manifestly passed the verdict and decided that the SPMF therapy is not specifically excluded and this treatment involves therapy where cartilage is regrown and this helps in slowing down the degenerative Arthritis. Moreover the Hon’ble National Commission further decided that issuing a Policy to a person of 61 years of age and then stating that ‘age related diseases’ are excluded amounts to unfair trade practice.

             Astonishingly particularly in this case the patient (wife of the Complainant) was of 61 years old aged lady in whose favour the said Insurance Policy was issued by the Opposite Party Insurance company and the patient (wife of the Complainant) was also suffered from the disease caused knee pain and was treated by same magnetic field Therapy (QMR Therapy) and similarly in the instant case the Opposite Party Insurance company repudiated the claim on the same ground as the said Therapy is excluded from the coverage of the Insurance Policy.

             Manifestly, the purpose of purchase the Mediclaim Policy by the customer/consumer is for getting benefit, when the said customer after his/her medical treatment may get the benefit of adjustment of the medical expenses. But it is not possible for any customer to guess forehead that he has been suffering from any disease, unless it is detected by any doctor, due to sudden exposer of any problem suffered by the customer/ consumer.

             In fact, the MediClaim Policy is a welfare policy and the said Policy is purchased by the customer/consumer, to get protection in his days of treatment and any customer can never predict that, from what type of disease he has suffering at the time of purchasing the Policy and signing the application for purchasing the said Policy.

              Finally, the Forum conclude that Insurance Co. is an authority to decide any claim of any insured, but such a decision is quasi judicial in nature. So, before repudiation of any claim the Insurance Company shall have to sure that the treatment adopted by the Consumer and/or beneficiary of the Insured is specifically excluded from the purview of the Policy terms and conditions. If such case where such treatment (QMR Therapy) is not specifically excluded, in that case repudiation is found illegal, unjustified and beyond the beneficial norms of the Insurance company.

              In view of the above proposition of the MediClaim Policy, we find that, the Insurance Company should allow the amount claimed by the Insured/bonafide Consumer to the claimant considering the fact that, he/ she is a bonafied consumer/customer Insured  to whom the valid policy was issued and  who duly paid the premium within due date which was received regularly and in the instant case the Opposite party Insurance Company never alleged that the Complainant ever failed to pay any premium and/or default to pay the same at least once.

              In fact, it is the trend of the Insurance company like this Opposite Parties that the Insurance company sell out their Policies through their Agent by inspiring the customers/consumers by offering many facilities but in reality when any of those Insured/customers/bonafide consumers availes such facilities and submitted their claim at that time the Insurance company shows their own teeth by repudiate those claims by any flimsy ground which is not justified at all and also thrashed by the Hon’ble National Commission in their Order.  

              Thus unanimously the Forum decided that the repudiation of the claim of the Complainant by the Opposite Parties is not justified and is totally illegal and beyond the natural justice and Consumer Law and amounts to ‘Unfair Trade Practice’ as observed by the Hon’ble National Commission and so the Opposite Parties are liable to reimburse the claim of the Complainant and to pay the sum of Rs. 1,10,785/- only with interest of 10 % p.a from the date of submitting the claim i.e. from 13.10.2010 till its full and final realization and also liable to pay the compensation for unnecessary sufferings, mental agony and for bearing harassment for such illegal and unjustified repudiation of the said claim towards the Complainant and also liable to pay the penal charges for adopting ‘Unfair Trade Practice’ to the Consumer Legal Aid Fund.

              Therefore, in the light of the above discussion, we are of the opinion that the Complainant is entitled to get the relief as prayed for and consequently the points for consideration are decided in affirmative.

             In short, the complainant deserves success.

             In the result, we proceed to pass

                                                                                O R D E R 

             That the complaint be and the same is allowed on contest against Opposite Party No. 1 & 2 both with cost of Rs. 10,000/- only payable by the Opposite party No. 1 & 2 both jointly and severally to the Complainant within one month from the date of this ‘Order’.

             That the Opposite Party No. 1 & 2 both jointly and severally are directed to pay an amount of Rs. 1,10,785/-  only to the Complainant along with 10 % interest p.a. from the date of submitting the claim i.e. from 13.10.2010 till its full and final realization to the Complainant within one month from the date of this ‘Order’.

              That the Opposite Party No. 1 & 2 both are jointly and severally be further directed to pay a sum of Rs. 20,000/-  only to the Complainant as compensation for unnecessary sufferings, harassment and mental agony for unjustified repudiation of the said claim within one month from the date of this ‘Order’.

               That the Opposite Party No. 1 & 2 both jointly and severally are directed to pay an amount of Rs. 20,000/- only to the Consumer Legal Aid Fund for adopting ‘Unfair Trade Practice’ by unjustifiably repudiated of the said claim  within one month from the date of this ‘Order’.

              In the event of non compliance of any portion of the order by the Opposite Party within a period of one month from the date of this ‘Order’, the Opposite Party shall have to pay a sum of Rs. 100/- per day, from the date of this order till its realization, as punitive damages, out of which amount 50 % amount shall have to pay to the Complainant and rest 50 % amount shall be deposited by the Opposite Party/s   to the Consumer legal Aid Fund.

            Let copies of the order be supplied to the parties free of cost when applied for.