IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM

Dated this the 30^th    day of August 2018

Present:   Sri. P.SatheeshChandran Nair, President

                            Sri. K.N. Radhakrishnan, Member

                            Smt..Renu.P.Gopalan, Member

CC No. 34/2013(Filed on 31/01/13)

Between:

Mohandas M.S

Anu Bhavan,

Aymanam PO

(Adv. N.C Preny)….…..Complainant

And:

1. Branch Manager,

Star Health & Allied

Insurance Co.Ltd,

Opp.CTO. MC Road, Kottayam

2. Managing Director

Star Health &Allied Insurance Co.Ltd.

Vallavar Kottam High Road,

Nangambakkam, Chennai 600034.

(OP 1 & 2 Adv Agi Jospeh)….Opposite parties

O R D E R

Sri. P.SatheeshChandran Nair, President

                The case of the complainant is as follows.  The complainant is a subscriber of Family Health Optima Insurance Policy of opposite party 1 vide policy No. P/181113/01/2012/001565.  The total premium of the insurance policy is Rs. 6105/- and the sum assured  is Rs.2,00,000/-.  The period of insurance is from 29/08/2011 to 28/08/2012.  It is contented that on 08/06/12  to13/06/12 the complainant underwent for treatment of Coronary Artery Disease in Cherian Ashram Holistic Centre Hospital.  Though the complainant intimated the reimbursement of the medical expenses incurred by the complainant the opposite party was not ready to reimburse the expenditure.  It is contended that the reason for the repudiation of reimbursement was that the hospital which the complainant was undergone treatment was not a hospital schedule for treatment as per the terms and conditions of the insurance.  It is further contented that the treatment provided by the said hospital was purely allopathic nature and also stated that the act of the opposite party is against law and facts.  Therefore the complainant filed this case for the reimbursement of the medical expenses Rs.24,905/- compensation, cost etc.etc.

          This Forum entertained the complaint and issued notice to opposite parties for appearance.  The opposite parties entered appearance and filed a joint version as follows.  According to the opposite parties the case is not maintainable either in law or on facts.  The opposite parties admitted the insurance policy and the duration of the policy as claimed by the complainant.  It is contended that the complainant undergone treatment at Cherian Ashramm Holistic Centre, Kottayam for the treatment of CAD and underwent EDTA Chelation therapy and discharged on 13/06/2012.  According to the opposite party the Chelation therapy is a standard and accepted treatment for lead poisoning.  More over the said treatment was an allopathic treatment as alleged by the complainant.  The National Medical Journal of India has also stated that this kind of treatment cannot  treated as an allopathic treatment as claimed.  As per the terms and conditions of the said policy the opposite party is not liable to pay any expenses incurred for treatment other than allopathic treatment.  It is further contented that the certificate issued one Dr.Ramani Bose is not at all acceptable since she is not a competent person to give such a certificate with regard to the CAD disease.  It is further contented that the opposite parties did not commit any deficiency in service or unfair trade practice as alleged by the complainant.  Therefore this opposite parties prayed to dismiss the complaint with cost.

          On the basis of the complaint, version and records before us we framed the following issued for consideration.

1. Whether the complaint is maintainable before the Forum?
2. Whether the opposite parties are committed any deficiency in service as alleged by the complainant?
3. Regarding relief and costs?

In order to prove the case of the complainant, complainant he who filed a proof affidavit and marked Ext.A1 to A7 in his favour.  Ext.A1 is the discharge card issued by Cherian Ashram Holistic centre dtd 13/6/12.  Ext.A2 is the copy of family health optima insurance policy schedule issued by Star Health and Allied Insurance Company Limited..  Ext.A3 is the copy of certificate issued by Dr.Mrs.Ramani Bose BSc., MBBS dated 7/9/12.  Ext.A4 is the copy of registration certificate.  Ext.A5 is the copy of claim form for medical insurance.  Ext.A6 is the copy of bill dated 13/6/12 issued by Cherian Ashram Holistic Centre.  Ext.A7 is the copy of letter dtd 7/9/12.  On the other side the Branch Manager of the opposite party one Balu M filed a proof affidavit in favour of them and marked Ext.B1 to B7 in their favour.  Ext.B1 is the Copy of Family Health Optima Insurance Policy Schedule.  Ext.B2 is the Discharge card issued by Cherian Ashram Holistic Centre dtd 13/6/12. Ext.B3 is the Claim form for Medical Insurance.  Ext.B4 is the repudiation letter dtd 8/9/12.  Ext.B5 is the letter of Medical Council of India No.MCI-7(10)/2016-RTI/131930 dtd 24/09/2016.  Ext.B6 is the certificate issued by Dr.Mrs. Ramani Bose B.Sc.MBBS dtd 7/9/12.  Ext.B7 is the letter dated 19/12/2012 issued by Star Health and Allied Insurance Co.Ltd.  As per the order in IA 182/17 the commissioner she who examined one Dr.Ramani Bose as a witness on the side of the complainant and filed a report along with deposition of the said person in  chief cross.  The deposition of the said doctor is treated as  deposition of PW1.  After the closure of evidence we heard both sides.

Point No.1

          The opposite parties herein strongly contended that this complaint is not maintainable either in law or on facts.  When we evaluate the evidence of both parties it is to be understood that complainant is a subscriber of the opposite parties Family Health Optima Insurance Policy.  It is also admitted that the complainant he who paid the premium of the said policy and the said policy was valid at the time of the treatment of the complainant.  Therefore we can easily found that the complainant is a consumer and the opposite parties are the service providers of the complainant.  Therefore point No.1 found infavour of the complainant.

Point No.2 & 3

          For the sake of convenience we would like to consider the Point No. 2 & 3 together. The complainant he who filed a proof affidavit along with 7 documents to prove his case.  When we go through the proof affidavit of the complainant we can see that the proof affidavit is more or less as per the tune of the compliant.  It is a definite case of the complainant   that he was having a valid Family Health Optima Insurance Policy with the opposite parties and he has all right to get a reimbursement for the treatment which he undergone at Cherian Ashram Holistic Centre, Kottayam.  It is deposed that for the said treatment he spend an amount of Rs.24905/- .  In order to substantiate the contention of the complainant he filed a discharge card of Cherian Ashram Holistic Centre Kottayam dated 8/6/12 which shows that his disease was Coronary Artery disease as per Ext. A1and  the procedure adopted by the said hospital was seen as ETDA Chelation therapy.  It also shows that at the time of discharge the complainant was advised to continue the cardiac medicines.  Ext.A2 is the  Family Health Optima Insurance policy certificate infavour of the complainant.  Ext.A3 is the certificate issued by Dr.Mrs.Ramani Bose BSc MBBs dtd 7/9/12 related to Cherian Ashram Holistic Centre Kottayam which certified that EDTA Chelation therapy is an allopathic treatment.  Ext.A4 is a copy of document which shows that the said Cherian Ashram Holistic Centre is registered as per the provisions of Panchayatraj Act.  Ext.A5 is a document which shows that the complainant filed a medical claim before the opposite party for the reimbursement of his medical claim.  In anywhere in Ext.A5 we are not in a position to see any claim of amount as contended by the complainant.  The 2^nd and 3^rd page of the Ext.A5 is seen blank.  The medical certificate  attached along with Ext.A5 shows that the treatment was a non surgical treatment.  Ext.A6 dtd 13/6/12 is a copy of medical bill issued by Cherian Ashram Holistic Centre Kottayam infavour of the complainant for Rs.24905/-.  Ext.A7 dtd 7/9/12 which shows that the complainant who served another request to reconsider his reimbursement claim to the opposite parties.  Apart from the above proof affidavit alongwith Ext.A1 to A7, Dr. Ramani Bose related to Cherian Ashram Holistic Centre hospital was also examined in this case through a commission advocate named Advt.Sunitha.  When we go through the chief examination of the said PW1 we can see that all the medicines applied to the complainant where allopathic medicines and also deposed that the doctor PW1 have no knowledge about  Ayurvedic medicines.  When we go through the deposition of PW1 cross “ Patient \v Chelation Therapy F¶ treatment BWv sN¿-X-Xv.  Dr. modern medicine practice  sN¿m-\mWv register sN¿n-Xn-cn¡p-¶-Xv.  R§-fpsS protocol medical council  sâ \nb-a-¯n\v hnt[-b-a-Ã. Medical council   sâ record {]Imcw Chelation Therapy India  bn AwKo-Ir-X-amb  treatment  AÃm-sb¶v ]d-bp¶p?  Ext. B5 shown to the witness I do agree with that   Cu Hospital- \v  DHMS AwKo-Imcw In«n-bn-«p-­v.  Ext.A6-  Ayurvedic medicine for 1 month F¶m-Wv Fgp-Xn-bn-cn-¡p-¶Xv”.  When we evaluate the testimony of PW1 in cross it shows that the Chelation therapy is not a recognized treatment in India.  The question to be decided here is whether the Chelation therapy comes under allopathic treatment or under Ayurvedic treatment.  The opposite party failed to establish any evidence to show that the therapy which was done by PW1 was an Ayurvedic treatment as deposed by PW1.

          The opposite party produced a proof affidavit of Executive Legal Officer from one Balu.M to substantiate their contention.  According to the opposite party their liability is only subject to the terms and conditions of the policy.  They produced the terms and conditions and schedule of the said policy as Ext.B1.  As per Ext.B2 dtd 8/6/12 we can see that the complainant’s disease was coronary artery disease and he was admitted in the hospital from 07/12/11 to 13/06/12.  Ext.B3 is the claim form for medical insurance which was filed by the complainant before the opposite party.  When we verify Ext.B3 we cannot see any details with regard to the claim of the complainant or with regard to the details of any current claim of the bill.  The 2^nd page of Ext.B3 is seen totally blank.  The 3^rd and 4^th page of the Ext.B3 is intended to be filled by the concerned doctor.  We can see the name seal and signature of the treated doctor PW1, in the 3^rd page of Ext.B3.  It is also stated that this patient has no significant past issues with regard to the duration of illness.  The nature of the treatment given to the patient was Chelation Therapy(EDTA) and also certify that this treatment was a nonsurgical treatment.  Ext. B4 dated 8/9/12 is the repudiation of the claim of the complainant by the opposite party.  Ext.B5 dated 24/09/16 is the letter issued by medical council of India infavour of the opposite parties counsel which describe that the Chelation Therapy is not a recognized system of medicine in the country.  When we evaluate this Ext.B5 we are not in a position to get the answer whether this treatment is an allopathic treatment or an Ayurvedic treatment.  Ext.B6 is a certificate issued by PW1 Dr. M/s. Ramani Bose dated 7/9/12 which shows that the Chalation therapy(EDTA) is an allopathic treatment done under the supervision of qualified allopathic doctor.  If so we are also bound to believe that the said treatment was an allopathic treatment as pleaded by the complainant.  When PW1 was cross examined by opposite party there is not even a single suggestion to disbelieve the testimony of PW1/Dr Ramani Bose with regard to Ext.B6.  Ext.B7 is a notice dated 19/12/12 issued to the said PW1/Dr Ramani Bose seeking her opinion with regard to the chelation therapy which she had done to the complainant.  Anyway on the basis of the above proof affidavit and Exts. B1 to B7 on opposite party’s side we are not in a position to see that the treatment done at Cherian Ashram Holistic Centre is an Ayurvedic treatment as contented by opposite parties in this case.

          On the basis of the above discussion we are of the view that there is no justification on opposite parties to repudiate the claim of reimbursement of the treatment expenses.  A person always joining this kinds of insurance scheme as a protection to their life and also for money saving.  When an insured admitted in a hospital and seeking reimbursement to the insurer, these kinds of flimsy grounds are not justifiable to repudiate their genuine claim.  Therefore we find that the opposite parties committed deficiency in service against the complainant and they are liable to the complainant.  Opposite party 1 is the Branch Manager and opposite party 2 is the Managing Director of the Star Health Allied Insurance Company Ltd.  Therefore we can find that opposite party 1 and opposite party 2 are jointly and severally liable to the complainant.  Hence point No.2 and 3 are also found infavour of the complainant.

          In the result we pass the following orders.

1. The opposite parties are hereby directed to pay an amount of Rs.24,905/- (Rupees Twenty four thousand nine hundred and five) as medical reimbursement to the complainant with 10% interest from the date of filing of this case ie 31/01/13 onwards.
2. The opposite parties are also directed to pay a compensation of Rs.7500/- (Rupees Seven thousand five hundred) and cost of Rs.2500/- (Rupees Two thousand five hundred) to the complainant with 10% interest from the date of receipt of this order onwards.

Dictated to the Confidential Assistant, transcribed and typed by her, corrected by me and pronounced in the Open Forum on this the 30^th day of August 2018.

                                                                                      Sd/-

 Sri. P.SatheeshChandran Nair,

                                              (President)

     Sri. K.N. Radhakrishnan, Member           Sd/-

    Smt..Renu.P.Gopalan, Member                Sd/-

Appendix

Witness examined on the side of complainant

PW1-Dr.Ramani Bose

Exhibits marked on the side of complainant.

A1- discharge card issued by Cherian Ashram Holistic centre dtd 13/6/12. 

A2- copy of family health optima insurance policy schedule issued by Star

        Health and Allied Insurance Company Limited..

A3- copy of certificate issued by Dr.Mrs.Ramani Bose BSc., MBBS dated 7/9/12.  A4- copy of registration certificate.

A5- copy of claim form for medical insurance. 

A6- copy of bill dated 13/6/12 issued by Cherian Ashram Holistic Centre. 

A7- copy of letter dtd 7/9/12.

Exhibits on the side of opposite parties

B1-Copy of Family Health Optima Insurance Policy Schedule. 

B2- Discharge card issued by Cherian Ashram Holistic Centre dtd 13/6/12.

B3 - Claim form for Medical Insurance.

B4 - repudiation letter dtd 8/9/12. 

B5 -letter of Medical Council of India No.MCI-7(10)/2016-RTI/131930

      dtd 24/09/2016. 

B6 - certificate issued by Dr.Mrs. Ramani Bose B.Sc.MBBS dtd. 7/9/12.

B7 - letter dated 19/12/2012 issued by Star Health and Allied Insurance Co.Ltd

By Order,

Senior Superintendent.

Copy to:

1)Mohandas M.S,Kochumannavathu,Anu Bhavan,

Aymanam PO,Kottayam

2. Branch Manager,  Star Health & Allied,Insurance Co.Ltd,
1.  

3)Managing Director,Star Health &Allied Insurance Co.Ltd.

Vallavar Kottam High Road,Nangambakkam, Chennai 600034

4)Stock file