Date of Filing:08/07/2014
Date of Order:24/01/2017
ORDER
BY SRI.SYED ANSER KHALEEM, PRESIDENT
1. This is the complaint filed under Section 12 of the Consumer Protection Act, 1986 against the opposite parties (hereinafter referred in short as O.Ps) alleging deficiency in service on the part of the O.Ps and prays for direction to the Ops to pay a sum of Rs.1,00,000/- and for Rs.20,000/- towards mental agony, trauma and hardship along with Rs.20,000/- towards cost of the proceedings.
2. The brief facts of the case set out in the complaint are that, the complainant had taken the insurance policy namely “Family Health Optima” and bearing policy No.P/141111/01/2013/004639 from the O.Ps. Complainant states that, who suffered severe pain in knee joints and on diagnosis by the doctor it reveals that presence of Osteoarthritis. Hence the complainant underwent treatment sequential programme magnetic therapy (SPMF) for 21 days consecutively at SBF Health care and Research Centre. On account of the said treatment, complainant resumed to normal day to day activities. The complainant further states that he incurred medical expenditure of Rs.1,00,000/- and paid to the SBF Health Care and Research Centre. Thereafter, complainant submitted the claim papers for reimbursement of the medical expenditure for Rs.1,00,000/- with the Ops, whereas the Ops through his letter dated: 23/09/2013 repudiated the claim of the complainant on the following grounds that, the treatment does warrant hospitalization which has no relevance to the facts of the matter and also the said treatment does not require hospitalization.
3. The complainant states that, as per the terms of the policy there is no whisper, the treatment for Osteoarthritis is precluded from seeking reimbursement. Hence the complainant got issued legal notice on 16/12/2013 demanding to pay reimbursement and the Ops have given untenable reply for repudiating the claim. Hence this complaint.
4. Upon issuance of notice, Op No.1 and 2 appeared through their counsel filed its version. In the version of Ops contended that, treatment availed by the is not at all covered by the Policy, further contended that in order to avail the benefit of the policy it is necessary for the insured to admit in the hospital for a period of 24 hours. Further contended that, there is no deficiency in service on the part of the O.Ps and O.P is bound to act as per the terms and conditions of the policy and one of the condition of the policy is that the insured person who is admitted to hospital and states their for a minimum period of 24 hours for the sole purpose of receiving the treatment and the complainant is not admitted for 24 hours as an inpatient. The O.P also contended that, complainant was admitted for 8 hours on first day for blood investigation, treatment, rehab exercises, pain management and observation and three hours rest for 21 days for of treatment of sequential programme magnetic field for one hour, followed by one hour for physiotherapy and one hour for observation in total three hours per day . Hence contended that the claim fell out side the purview of the policy risk coverage the repudiation was intimated on 25.9.2013. On other grounds O.Ps prays for dismissal of the complaint.
5. In order to substantiate the case of the parties and complainant filed his affidavit evidence and also heard the arguments.
6. On the basis of the pleadings of the complainant, the following points will arise for our consideration are:-
(A) Whether the complainant has proved
deficiency in service on the part of the O.Ps?
(B) Whether the complainant is entitled to
the relief prayed for in the complaint?
(C) What order?
7. Our answers to the above points are:-
POINT (A) & (B): In the affirmative.
POINT (C): As per the final order
for the following:
REASONS
POINT No.(A) & (B):-
8. On perusing the pleading of the parties and on the basis of the available evidence on record, it is not in dispute that the complainant by availing the services of the Ops taken the insurance policy namely “Family Health Optima” and bearing policy No.P/141111/01/2013/004639 from the O.Ps. Further it is also not in dispute complainants in order to overcome the Osteoarthritis in both knees undergone treatment using sequential programmed Magnetic Field Therapy (SPMF Therapy) for 21 days consecutively at SBF Health Care & Research Centre.
9. Per-contra, this contesting OP contended that, as per terms of the policy the complainant has taken treatment only as an Out Patient without being admitted to the hospital, which is a permanent exclusion. On this ground, this OP justifies the repudiation of the claim.
10. In order to prove the case of the complainant, the complainant has filed his affidavit evidence and deposed in the evidence almost all the facts averred in the complaint. Further complainant filed the consolidated invoice dated:03.07.2013, it discloses that complainant paid Rs.93,700/- towards the SBMF Therapy including physiotherapy charges for 21 days. Further on perusal of claim repudiation letter dated:25/09/2013, it reveals that, the repudiation on the ground only that the complainant has taken the treatment on OPD basis and on the basis of terms and conditions of the policy OPD based treatments are not covered.
11. The complainant taken treatment for 21 days and using the SPMF therapy for one hour every day followed by physiotherapy for half an hour continuously for 21 days and the same is not denied by the Ops. For each and every case the line of treatment is decided by the doctor who treats the patient by admitting the patient to the hospital or as an OPD. But treatment is a treatment and the complainant has took more than 21 days treatment by visiting the hospital everyday continuously. Hence the repudiation by the OP is not justifiable one and they cannot take flimsy ground to exonerate their liability.
12. The Advocate for the complainant drawn our attention to the decision of the Hon’ble National Commission in Revision Petition No: 2362/2014 decided on 23/02/2015. On perusal of the same, it was held that, the Good Health Policy Certificate issued to the insured at the age of 61 years. Issuing policy to a person of 61 years of age and then stating that age related diseases are excluded amounts to unfair trade practice. When the SPMF Therapy is not specifically excluded, the act of the Ops in repudiating claim amounts to deficiency in service. On going through the entire facts involved in the above said decision is almost similar to the facts involved in the present case on hand and the ratio of the above decision is aptly applicable to present case on hand. Even the our own Hon’ble State Commission held that, “Even if the treatment has taken by the patient as an Out Patient without admitting as an In-Patient is entitled to claim reimbursement”. The main purpose of getting the Medi-claim policy is to get reimbursement as the Osteoarthritis is bound to occur in the elderly people cannot be denied.
13. It is worth to note that, the complainant was produced the letter of appreciation given by the then Hon’ble President of India appreciating the line of treatment given to the patients who are suffering from Osteoarthritis. It is obvious that, the line of treatment against the development of science is differ from time to time and the needy will reap the benefits. But the insurance company stick on to the old terms and conditions, as the world is so advanced the norms of the insurance company has to be construed in terms of the prevailing conditions. Hence based on mere technical reasons the insurer cannot exonerate their liability towards their customers.
14. In the light of above discussion, we reach to conclusion that, complainant proved deficiency in service on the part of the Ops. Further the Ops made the complainant to wander from pillar to post in the old age. In the attendant circumstances of the case, we deem it just and proper that the Ops are jointly and severally liable to pay a sum of Rs.93,700/- along with interest at the rate of 12% from the date of repudiation i.e. from 25/09/2013 till realization of the amount. Further, the Ops are also directed to pay Rs.2,000/- towards cost of litigation it will meet the ends of justice. Accordingly, we answered these points in the affirmative.
POINT No. (C):-
15. On the basis of the findings given on the point No. (A) and (B) and in the result, we proceed to pass the following:-
ORDER
1. The complaint is allowed in part with cost.
2. The OP.No.1 and 2 are jointly and severally hereby directed to pay a sum of Rs.93,700/- along with interest at the rate of 12% per annum from the date of repudiation i.e. 25/09/2013 till realization of the amount to the complainant.
3. Further O.Ps are also directed to pay Rs.2,000/- towards cost of the litigation expenses.
4. The O.Ps are hereby directed to comply the order of this Forum within 30 days from the date of receipt of this order and submit the compliance report to this forum within 45 days from the date of receipt of this order.
5. Send a copy of this order to both parties free of cost.
(Dictated to the Stenographer, transcribed and computerized by him, corrected and then pronounced by us in the Open Forum on this the 24th Day of January 2017)
MEMBER MEMBER PRESIDENT
*Rak
