PER SHRI. S.S.PATIL - HON’BLE  MEMBER :

1)        This is the complaint regarding the deficiency in service on the part of Opposite Parties as they repudiated the mediclaim insurance of the Complainant on flimsy ground as alleged by the Complainant.  The facts of this case as stated by the Complainant are that the Complainant has taken a Mediclaim Policy bearing No.111400/48/2009/310 from the Opposite Party No.1 for the period from 05/06/08 to 04/06/09.  It was further renewed for the period from 05/06/09 to 04/06/2010 and the policy number was 111400/48/2010/709.  The insurance policy was in force since 05/06/2002 and the family of the Complainant was insured under the cover of this policy.  During the validity of the said mediclaim policy, the Complainant went under Coronary Angiography at Cumballa Hill Hospital on 18/03/2009.  He was diagnosed as suffering from Ischemic Heart Disease & was advised bypass surgery at IPC Heart Centre, the Complainant was advised Enhanced External Counter Pulsation Treatment (EECP Treatment). The Complainant preferred EECP treatment which was non invasive and low cost treatment. 

2)        The Complainant has further stated that he underwent 45 sittings of EECP treatment at IPC Heart Centre costing Rs.3,000/- each sitting.  However, the heart Centre offered a package treatment for Rs.1 Lac only.  The treatment lasted from 22/04/09 to 22/06/09.  On 12/05/09, the Complainant informed Opposite Party No.2 regarding the treatment and estimated cost for the treatment.  Thereafter, he filed claim form alongwith bills and receipts for the expenses and claimed an amount of Rs.1,10,515/-.

3)        The Complainant has further stated that the Opposite Party No.2 vide its letter dtd.27/07/09 communicated to Opposite Party No.1 that the investigations done and supportive treatment given are consistent with the disease and the line of treatment in this case is in  accordance with the diagnosis but falling under exclusion clause 4.13.  The expenses related to unproven procedure or treatments are not payable.  Hence, the claim is not in order and non admissible.  The Complainant has stated that the above opinion is not acceptable.  It is the contention of the Complainant that he brought to the notice of the Opposite Party that the treatment i.e. EECP, given to him is the proven treatment and adopted by many hospitals in India.  It is also recognized by the Government of India and other Insurance Companies but Opposite Party No.1 refused to accept the contention of the Complainant.  The Complainant has vehemently stated that he produced sufficient evidence to prove that the EECP treatment is a proven medical treatment but the Opposite Parties did not accept the same.

4)        The Complainant has further stated that he is liable to receive his legitimate claim of Rs.1,10,515/- with interest from the Opposite Parties.  He is also entitled to the compensation for causing mental agony, physical inconvenience to the Complainant and the cost.

5)        The Complainant has attached the xerox copies of the following documents in support of his complaint –

            a) Relevant Insurance Polices.

            b) Letter of the Complainant dtd.11/05/09.

            c) Claim form, medical bills submitted to Opposite Party No.2.

            d) Letter dtd.27/07/09.

            e) Letters dtd.12/08/09 and 29/08/09.

            f) Letter of rejection dtd.04/09/09.

            g) Letter dtd.04/09/09 and 17/09/09.

            h) Rejection letter dtd.15/12/09.

            i)  Letter dtd.12/01/09.

            j)  Document supporting the claim of the Complainant.

            k) Document from IPC Heart Centre

            l)  Editorial & other articles in News Bulletin MAH MA.

            m) Judgement dtd.21/11/07 by Thane Dist. Forum.

            n) Claim settlement advice by other Insurance Companies.

6)        The Opposite Parties were served with notices of the complaint filed by the Complainant.  Inspite of service of notice Opposite Party No.2 remained absent hence, an ex-parte order was passed against the Opposite Party No.2.  Opposite Party No.1 – the insurer filed its written statement wherein it denied the allegations of deficiency.  However, the Opposite Party No.1 has admitted that the Complainant has obtained a Mediclaim Policy for himself and his family members.  The Complainant was covered for a sum of Rs.1.25 Lac.  The Complainant underwent a Coronary Angiography on 10/03/09, during the validity of the insurance policy.  He was diagnosed for heart disease.  Thereafter, he underwent EECP procedure at IPC Heart Care Centre for the said disease.  For this treatment the Complainant submitted bills of Rs.1,10,515/- and consequently a claim of Rs.1,10,515/-.  The Opposite Party No.1 also admitted that it repudiated the claim as per the advice of Opposite Party No.2 vide its letter dtd.15/12/09 as per clause 4.13 of the policy.  The clause 4.13 states that the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of Naturopathy treatment, unproven procedure or treatment experiment or alternative medicine and related treatment including acupuncture, magnetic& such other therapies, etc. 

7)        The Opposite Party No.1 has further stated that, as per the policy condition 2.3 which states that expense on hospitalization are admissible only if the hospitalization is for minimum period of 24 hours.  In the present complaint, the treatment does not fall under the waiver of 24 hour hospitalization clause.  It is evident from the discharge summary of the patient (Complainant) that the treatment was received in different sitting for an hour every day meaning that it was an outpatient procedure.  Thus, the EECP treatment given to the patient does not involve hospitalization.  Considering all these aspects, the Opposite Party No.1 repudiated the claim.  The same view was also taken by the Ombudsman and rejected the claim.  Finally the Opposite Party No.1 has denied each and every allegation of the Complainant and prayed for dismissal of the complaint with cost.

8)        Thereafter, the Complainant has filed an affidavit of evidence wherein he was reiterated the facts mentioned in the complaint and has further explained that he was suffering from heart disease as diagnosed by angiography done on 18/03/09.  Therefore, he underwent E..E.C.P. treatment under Pratiksha DebDas, M.D. at IPC Heart Centre.  This treatment is non invasive globally accepted low cost treatment in place of bypass surgery.

9)        The Complainant has further explained that, he underwent 45 sittings for this treatment from 22/04/09 to 22/06/09. He informed the Opposite Party No.2 about the treatment vide his letter dtd.11/05/09.  For this treatment he incurred expenses of Rs.1,10,515/- and therefore he submitted his claim of Rs.1,10,515/- to Opposite Party No.1.  However, the Opposite Party No.1 repudiated the claim as per exclusion clause 4.13 of the policy.  However, the Complainant has vehemently stated in his affidavit that EECP treatment is a proven treatment.

10)      The Complainant has referred the documents marked as Exh.‘M’ to the complaint and stated that these documents show that EECP treatment is worldly recognized procedure to care heart disease. A letter from IPC Heart Centre Hospital  states that the EECP is approved non invasive technology, it is USFDA approved procedure and ISO 9001 Certified one.  Dr. Deepak Jumani, Editor of Indian Medical Association, Maharashtra Branch, has also supported the above contention.

11)      The Complainant has submitted, the judgement of Thane District Consumer Disputes Redressal Forum in the similar matter, directing the Opposite Party to reimburse the charges incurred by the Complainant for EECP treatment. The Complainant has also annexed the claim settlement letter by the health Service Pvt. Ltd., Bajaj Allianz, General Insurance Co. and Royal Sunderam Alliance Co. Ltd. allowing the claim for EECP treatment.  

12)      The Complainant has pointed out that the Opposite Party has not filed a single document in support of its written statement. It is a bald and bare denial, not supported by any medical text and hence, cannot be relied upon.  The Opposite Party has not annexed any evidence to show that the EECP treatment is not a recognized and approved treatment and therefore, its claim that the exclusion clause 4.13 is attracted, should not be accepted.  The Opposite Party has not filed any document to show that the EECP treatment is not proven one.

13)      The Complainant has also pointed out that, though the Opposite Party repudiated his entire claim as stated above, the Opposite Party sent a cheque of Rs.6,389/- towards full & final settlement of his claim vide letter dtd.07/03/2011 i.e. after filing this complaint.  However, the Complainant has not signed the discharge voucher.  Therefore, the Opposite Party cannot take contradictory stand on the same issue.

14)      The Opposite Party also filed its affidavit of evidence, wherein it reiterated the points and facts mentioned in its written statement.  However, it has mentioned in para 6 of the affidavit of evidence that it has annexed the copy of the order of Ombudsman at Exh.‘D’ but there is nothing on record as the copy of Ombudsman at Exh.‘D’.  No exhibit is attached with the affidavit evidence of Mr. A.N. Singh as Opposite Party No.1.

15)      Thereafter, the Opposite Party No.1 and the Complainant also filed their written arguments wherein they have reiterated the facts and points mentioned in their respective written statement and the complaint.

16)      We heard the Ld.Advocates for the Complainant and Opposite Party.  we also perused the papers submitted by both the parties and our findings are as follows –

            The Complainant has obtained a mediclaim policy from the Opposite Party No.1 and during the validity of the mediclaim policy the Complainant suffered the heart disease for which he underwent Enhanced External Counter Pulsation (E.E.C.P.) treatment at IPC Heart Care Pvt. Ltd., Mumbai. For this treatment he incurred expenses of Rs.1,10,515/-.  In this case the point of dispute is that the Complainant was not hospitalized continuously from 22/04/09 to 22/06/09 but he underwent the above treatment in 45 sittings in the above said period of 60 days, meaning thereby he underwent about 1 hour every day hospitalization. In other words he was a out patient.

17)      However, the Opposite Party has repudiated the claim of the Complainant as per clause 4.13 of the policy and not as per clause 2.3.  Clause 4.13 of policy is as follows -

            “The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of Naturopathy treatment, unproven procedure or treatment, experiment or alternative medicine and related treatment including acupuncture, magnetic and such other therapies.”

18)      The Opposite Party has stated that the EECP treatment is unproven procedure or treatment.  On the contrary the Complainant has submitted documents to show that it is a proven treatment, globally accepted non invasive low cost treatment for the heart disease.  The Complainant has taken a proven EECP treatment in 45 sittings in a span of two months.

19)      IN the similar type of complaint, the Thane District Consumer Disputes Redressal Forum has allowed the complaint and ordered the Insurance Company to reimburse the expenses incurred by the Complainant for EECP treatment.

20)      The Bajaj Allianz Insurance and other Insurance Companies have settled the insurance claims pertaining to EECP treatment.  The Complainant has produced the settled cases alongwith his affidavit of evidence. Therefore, in our view the Complainant was suffering from heart ailment.  He has obtained a proven treatment for which he has incurred expenses of Rs.1,10,515/- but Opposite Party repudiated the claim as per clause 4.13 of the policy.  However, the Opposite Party has not proved that the treatment taken by the Complainant is unproven or it is a naturopathy or alternative medicine/treatment like acupuncture, etc.  Therefore, the Opposite Parties have not established that the case of the Complainant falls under clause 4.13 of the policy.  Therefore, the Opposite Parties have wrongly repudiated the claim and hence, Opposite Parties are liable to reimburse the above said expenses incurred by the Complainant while undergoing the above said treatment. Opposite Parties are also liable for compensation for mental agony and the cost.  In view of the above findings we pass the order as follows –

                                                                                             O R D E R

            1.    Complaint No.351/2010 is partly allowed.

2.         The Opposite Party No.1 & 2 are directed to reimburse jointly and/or severally Rs.1,10,515/- (Rs. One Lac Ten Thousand Five Hundred Fifteen Only) to the Complainant with interest @ 9 % p.a. from 04/09/2009 till payment.

3.         The Opposite Party No.1 & 2 are also directed to pay jointly and/or severally Rs.10,000/- (Rs. Ten Thousand Only) to the Complainant for mental agony caused to the Complainant as it repudiated the claim on wrong ground.

4.         The Opposite Party are also directed to pay jointly and/or severally Rs.5,000/- (Rs. Five Thousand Only) to the Complainant towards the cost of this complaint.  

5.    Opposite Parties are directed to comply with this order jointly and/or severally within 30 days from the receipt of copy of this order.

6.    Certified copies of this order be furnished to the parties.