SMT. RAVI SUSHA  : PRESIDENT

   Complaint has been  filed  by the complainant U/S  35 of the Consumer Protection Act 2019  seeking to get an  order directing  opposite parties to pay Rs.1,35,000/- towards treatment expense of the wife of the complainant   together with interest  alleging  deficiency of service on the part of opposite parties

    The facts of the case are that the complainant had submitted re-imbursement  of mediclaim  on behalf of his wife that she had undergone treatment for  spondiluties, acute back pain and knee pain.  She was admitted to an Ayurvedic Hospital at Thalassery from  31/12/2018 to 14/1/2019 as an inpatient, she was under treatment of Ayurvedic Doctor, Dr.Amit Ramesh,DAMS.  The treatment was a package  one which includes  doctor’s fee, nursing expenses, ayurvedic  therapies, oil massages, naadi  corrections etc  the bills  from hospitals clearly mentions those treatments.  It is submitted that  the complainant has  been taking  staff medi claim policy from the date of inception of  medi claim from 1986 onwards.  The treatment got  to his spouse is of  ayurvedic treatments, which is payable under medi claim policy.  The hospitals main treatment is ayurvedic treatment, they are conducting other alternative treatments as alleged by the OP is  not availed  reason to repudiate  the  claim of the complainant.  Hence the complaint.

After receiving notice, 1^st OP filed detailed version  admitting the  treatment of  complainant’s  wife and  submitting the claim  and repudiate the claim.  According to  1^st OP the complainant is not entitled to claim  for the re-imbursement of the medical expenses as per the exclusion clause 4.14 of the policy conditions.  While processing the claim of the  complainant by the 3^rd party administrator of the OP, it is found that the treatment undergone by  the complainant’s wife comes under the purview of unproven experimental treatment as the same consists of multiple experimental treatment like Marmachikiltsa, , steam bath, Naadi correction, yoga therapy etc which are all excluded as per the  exclusion clause 4.14 of the insurance policy   the  insurance company is not liable to make any insured  in connection or in  respect of the  medical expenses  whatever incurred by any insured  or in  respect of the expenses incurred for Naturopathy treatment, Acupressure , acupuncture ,magnetic Therapies, experimental and unproven treatments/ therapies are specifically excluded from the purview /benefit of the policy. The OP further submitted that the claim is not maintainable as the clause 5.5 of the policy since the complainant has not submitted  the original  medical documents, bills , receipts cash memo, which are all supported by proper prescriptions as required  by the 3^rd party administrator  of  OP for processing the claim , which is  a mandatory  requirement  as per the policy conditions if all the claim of the insured is to be considered.  Hence prayed for the dismissal of the complaint.

   As per the contentions raised by 1^st OP, Additional 2^nd OP was impleaded as per IA NO.308/2022 dtd.26/12/2022.

   Additional 2^nd OP filed separate version stating that the 2^nd OP insured the employees of the 1^st OP, including the complainant herein  as of group  mediclaim  policy for the period from 1/4/2018 to 31/3/2019.  The liability of this OP  for reimbursement of medical expense to the persons covered under the policy is according to the terms and conditions of the  policy  From the records for the alleged treatment undergone by the complainant, it is apparent that the alleged treatment on complainant is specifically excluded from benefit  under clause 4.15 of the policy,  the treatment centre where the complainant’s wife had undergone the alleged treatment is not a licensed, approved or recognized by any of the statutory organizations or bodies and the doctor , Dr.Amit Ramesh who treated the patient is not a qualified physician under any of the approved medicinal systems.  2^nd OP further submitted that  no legally valid invoice or bills were produced by the complainant and the documents produced by the complainant did not show any relevant and material particulars of the treatment centre  nor the qualification of the alleged  person  under whom the  treatment was taken.  Besides the specific branch of medicine followed in the   alleged treatment  is also not stated in any of the  records  pertaining to the alleged treatment.  Moreover the complainant had not complied  conditions 5.4 and 5.5 of the policy.  Further submitted that the complainant himself states that his wife was not in a position to do  any yoga  or yoga therapy.  None of the documents produced by the complainant is either genuine or reliable or authenticated. The complainant is not entitled to get any amount from this OP hence prayed for the dismissal of the complaint.

    Complainant has filed his chief affidavit and documents.  He has been examined as PW1 and marked  the documents as Exts.A1 to A5 series.  PW1 was subjected to cross examination by 2^nd OP.  2^nd OP submitted the policy schedule which was marked as Ext.B1.  After that complainant and the learned counsel of 2^nd OP  made oral argument.

   Complainant’s case is that the treatment availed by his wife  was a package one which includes Ayurvedic Therapies, oil massages, nadi correctness etc.  According to complainant, the treatment availed was Ayurvedic treatments from a qualified doctor and since he has taken staff mediclaim policy from   2^nd OP  from 1986 onwards, he  is eligible to get the  reimbursement of treatment expense of his wife.

   On the other hand, the learned counsel for the 2^nd OP submitted that the beneficiaries could avail of medical benefits only as per the terms and conditions of the policy.  OP has produced the  group health policy with terms and conditions marked as Ext.B1.  1^st contention of OPs is that under clause 4.15 of the Exclusion clause provided under the policy(Ext.B1) the alleged treatment on the  complainant’s wife is excluded  from benefit.  It is submitted that as per clause 4.15, expenses incurred for Naturopathy treatment, Acupressure magnetic Therapies, experimental and unproven treatments/ therapies are specifically excluded from the purview /benefit of the policy.  Another contention of OPs  is that the treatment centre where the complainant’s wife had undergone the alleged treatment is not a licensed, approved or recognized by any of the statutory organizations or bodies and the doctor , Dr.Amit Ramesh who treated the patient is not a qualified physician under any of the approved medicinal systems.  Further OPs contended that complainant had not complied conditions 5.4 and 5.5 of the policy  that” Notice of communication , upon the happening of any event which may give rise to a claim under this policy notice with full particulars shall be sent to the TPA named the schedule immediately and in case of  emergency hospitalization within 24 hours from the time of  hospitalization/ Domiciliary hospitalization, All supporting documents relating to the claim must be  filed  with PTA within 15 days from the date of discharge from the hospital.  In case of post hospitalization, treatment limited  to 60 days), all claim documents should be submitted within 7 days after completion of such treatment.    

     Learned counsel of 2^nd OP submitted that in this case, the complainant did not follow  any of the these procedures which he was required to, being a beneficiary under the  policy terms.  Further submitted that  under the circumstances, the claim for reimbursement was rightly refused.

   We have heard the complainant and the learned counsel for 2^nd OP and have gone  through the evidence on record including the terms and conditions in Ext.B1 policy.  A reading of clause 3.3.” For Ayurvedic treatment, hospitalization expenses are admissible only when the treatment has been  undergone in a Govt. Hospital or in any institute recognized by the  Govt. and /or accredited  by Quality council of India/National Accreditation  Board on health.”  It is seen that in Exts.A2&A3, the license number of the  treatment centre is not mentioned.

     Further, the procedure for availing medical benefit is also  clearly  stated in the same policy  Ext.B1 in clause 4.15 and  notice of communication is stated in clause 5.4 and 5.5.  In the instant  case though  complainant proved that the medical practitioner Dr.Amit Ramesh is a qualified doctor in BAMS, complainant failed to prove that the Ayurvedic  centre from where  complainant’s wife availed ayurvedic treatment is a Govt. Hospital or recognized by the government as per clause 3.3 and it is also clear that complainant did not comply  to the terms and conditions of the Health insurance policy clause 4.15, 5.4 and 5.5.  It is clear in Ext.A4 series that the procedure done was Ayushman treatment, Yoga therapy etc.

  Hence as per the facts and circumstances as stated above, we are of the view that complainant failed to prove the averment that  complainant’s wife is eligible to get the medical  benefits as per the terms  in Ext.B1 health insurance policy.  So there is no deficiency of service on the part of opposite parties.

   In the result complaint fails and hence the same is dismissed.  No order as to cost.

Exts:

A1- Insurance policy

A2- Discharge summary(subject to proof)

A3 series- Bills(subject to proof)

A4 series- copy of insurance policy

A5 series- Registration certificates

B1- policy schedule

PW1-Mahesh.C.M-complainant

Sd/                                                   Sd/                                                     Sd/

PRESIDENT                                             MEMBER                                               MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva           

                                                                        /Forwarded by Order/

                                                                   ASSISTANT REGISTRAR