BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

   27^th DAY OF NOVEMBER 2020

ORDER

SMT.PRATHIBHA. R.K., PRESIDENT

This complaint is filed by the complainant against the Opposite Parties (hereinafter called as OPs) under section 12 of the Consumer Protection Act, 1986.  The complainant prays to direct the OPs to reimburse the legitimate claim of Rs.3,76,006/-, to pay Rs.30,000/- towards mental agony, trauma and hardship and to pay Rs.20,000/- towards cost of the legal expenses together with interest @ 16% p.a from the date of repudiation.

2.      The brief facts of complaint is as under:

Complainant submitted that, based on the representations made by OPs, son of complainant was prevailed upon to take the Mediclaim Insurance Policy (Group) by paying premiums towards policy bearing No.520000/48/2017/659.  Complainant earlier diagnosed with ‘Metastatic Urothelial Carcinoma’ (Cancer in the bladder) was experiencing generalized weakness and low appetite which practically curtailed his day to day living and decided to seek medical investigation by way of MRI of the abdomen and pelvis, which revealed presence of multiple enlarged lymph nodes in the ‘aorto caval’ and ‘left para aortic’ location. 

 Based on this, the medical advice was to undergo treatment using Sequentially Programmed Magnetic Field Therapy (SPMF Therapy) for 28 days consecutively at SBF Healthcare and Research Centre of which Wg. Cdr. Dr.V.G Vasishta (Retd) is the C.E.O.  During the treatment the affected areas were treated using the SPMF therapy, two hours every day.  The treatment afforded has resulted in substantial relief from the ailment and has increased his mobility and quality of life substantially by causing a recession of the cancer in the body, which enabled the complainant to resume his normal day to day activities.

Complainant further submitted that in all he has incurred expenses of Rs.3,00,000/- for the said treatment and the same was paid to SBF Healthcare and Research Centre by way of cheque.  The complainant after having obtained the necessary details of the treatment afforded to him has lodged a claim for payment of Rs.3,76,006/- based on the treatment summary and consolidated bill duly given by the SBF Healthcare and Research Centre dated 14.10.2017.  The same was repudiated by the OPs by two communications, one undated and the other dated 28.02.2018 on the following grounds.

Repudiation reason for the undated communication:

“Clause 4.13: Naturopathy Treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies.”

Repudiation reason for the communication dated 28.02.2018:

“Claim is of metastatic urothelial carcinoma, the submitted bills are of opd, as opd is not covered in the policy terms and conditions so hence the claim is rejected under the clause 4.23 Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.”

Complainant further submitted that, the first undated repudiation letter was for the therapy as well as the pre-hospitalization expenses, the subject matter of which was a sum of Rs.3,45,604/- and the communication dated 28.02.2018 was for post hospitalization expenses, the subject matter of which was sum of Rs.30,402/-.  That the reason is duly illegal, unwarranted and the legitimate claim of the complainant was rejected only in order not to pay the legitimate amount expended by the complainant for which, the complainant was eminently eligible for reimbursement.  In this regard the complainant submitted that earlier, the treatment for cancer such as the one the complainant was suffering from chemotherapy, which is not at all advisable for a reason of 75 years as there is an invasion of poisonous substances in the body due to which there is not only a high mortality rate but also expensive covering number of days of hospitalization.  Wg. Cdr. Dr. V.G Vasishta (Retd) who has an MD in Radiology has conducted extensive research in the said field.  The research and clinical trials indicated substantial relief to several patients and therefore have been published in several National and International journals of repute.  Wg. Cdr. Dr.V.G Vasishta (Retd) has successfully treated hundreds of patients from different walks of life and also such dignitaries as Her Excellency Mrs. Pratibha Patil, former Hon’ble President of India, Mrs.Renuka Chowdhury, former Hon’ble Minister for Women and Child Development, Air Chief Marshall I.H Latif (Retd), former Chief of the Air Staff, Ambassador to France, Governor of Maharashtra and Governor of Uttarkhand who have given laudable remarks commending the treatment afforded to them by Wg. Cdr. Dr. V.G Vasishta (Retd) who is the Chief Executive Officer of SBF Healthcare and Research Centre. 

Complainant further submitted that as per the terms of the policy, there is no whisper that the treatment for cancer is precluded from seeking reimbursement.  The very clauses quoted by the OP has no application at all to the facts and circumstances of the case.  That the treatment is a result of technological advances which results in the recession of the cancer.  Furthermore, as enumerated above, the said therapy is the brain child of Wg. Cdr. Dr. V.G Vasishta (Retd) who is a highly qualified professional and has an MD in Radiology.  The same fact has also survived the test of the Hon’ble Consumer Fora and cannot be considered a ground for repudiation.  Moreover, in respect of age related disorders and repudiation of claim of insurance after collecting premiums from senior citizens amounts to unfair trade practice.

Complainant further submitted that the similar claims have been allowed by OPs and therefore repudiating the claim of the complainant amounts to discrimination.  The complainant reserves the right to take appropriate legal action against the blatant discrimination before appropriate authorities.  Complainant caused legal notice to OPs dated 11.04.2018 calling upon the OPs to reimburse the amount claimed by the complainant.  OPs have not properly responded to the legal notice.  Complainant felt deficiency in service on the part of OPs.  Hence complainant filed this complaint.

3. In response to the notice issued, OPs.1, 2 & 3 appeared through their advocate and filed their version in brief as under:

The OPs.1, 2 & 3 submits that the complaint is not maintainable in law or on facts.  The complainant sought for reimbursement of the claim amount of Rs.3,76,006/-, Rs.30,000/- towards mental agony, trauma, hardship and legal expenses of Rs.20,000/- with 16% interest from the OPs.  The said alleged claim is not proper one.  The complainant has not made any specific pleadings with respect to the deficiency in service done to the complainant by the OPs.1, 2 & 3.  The complaint is liable to be rejected as against OPs due to proper non-disclosure of the cause of action.

OPs.1, 2 & 4 is a public sector undertaking wholly owned by the Government of India and is engaged in non-life insurance.  There is no any negligence or deficiency of service on the part of OPs.1, 2 & 4.  OPs.1, 2 & 4 admits the issuance of the medi-claim insurance policy (Group) i.e., Family Health Plan Insurance TPA Ltd., in favour of the Huawei Technologies India Pvt. Ltd.  The policy bearing No.520000/48/2017/659 and the period was generated from 24.10.2016 to 23.10.2017.  However the liability of these OPs to indemnify the complainant is strictly subject to the terms and conditions of the policy.

OPs.1, 2 & 4 submitted that the complainant son is working in Huawei Technologies India Pvt. Ltd.  Complainant admitted and took the treatment from 17.09.2017 to 14.10.2017 in SBF Healthcare Pvt. Ltd.  The treatment underwent by the complainant is Metastatic Poorly Differentiated Urothelial Carcinoma, wherein 2 hours every day for 28 days, the complainant consecutive days took treatment from the said Health Centre.  The complainant took treatment as an outpatient diagnosis.  The treatment underwent by the complainant comes under the following exclusions clauses of the terms and conditions of the policy.

4. Exclusions:

The company shall not liable to make any payment under this policy in respect of any policy whatsoever uncured by any insured person in connection with or in respect of:

4.13 – Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc.

Admittedly the complainant has taken the treatment of Sequentially Programmed Magnetic field therapy.  Hence the complainant’s treatment attracts the 4.13 of the exclusion clause of the policy.  The OPs after verifying the records have repudiated the said claim.  The same is in accordance with the terms and conditions of the policy.

Even as per 4.23 – Outpatient Diagnostic, Medical or surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy.

As per the records produced by the complainant, he took treatment 2 hours every day as an outpatient but not as an in-patient.  Complainant has not followed the contract of agreement/policy.  Therefore these OPs are not liable to pay the said alleged amount. 

OPs.1, 2 & 4 further submitted that the treatment underwent by the complainant comes under the exclusion clauses of the terms and conditions of the policy.  Further OPs submitted that it is partially true to an extent that the son of the complainant company has obtained the policy and the complainant underwent the treatment as specified in the treatment summary.  Further partially it is true that the complainant has not made a claim before these OPs but these OPs have repudiated the claim based upon the terms and conditions of the policy clause No.4.13 and 4.23.  The same is proper.  Other averments regarding the amount are not admitted by these respondents.  There is no question of unfair trade practice has been adopted by these OPs.  The complainant has not followed the clause No.4.13 and 4.23 of policy.  Hence OPs have rejected the claim.  There is no any deficiency in service on the part of OPs.  Rest of the allegations made by the complainant is denied by the OPs.1, 2 & 4.  Hence OPs.1, 2 & 4 have prayed to dismiss the complaint with exemplary costs.

4. In response to notice issued, OP-3 appeared through their authorized representative and filed their version in brief as under:

OP-3 appointed by the Oriental Insurance Company to render the services against the policy bearing No.520000/48/2017/659.  The said policy is valid from 01.08.2017 to 23.10.2017 and for the policy No.520000/48/2018/1107 valid from 24.10.2017 to 23.10.2018 pertaining to the Corporate “Huawei Technologies India Pvt. Ltd : Parents”.  The complainant has enrolled with OP-3 bearing UHID No.17241562.  The complainant admitted to the hospital on 17.09.2017 due to the medical illness of “Metastatic Poorly differentiated urothelial carcinoma” and he underwent the procedure Sequentially Programmed Magnetic Field (SPMF) therapy at SBF Healthcare Pvt Ltd., Bangalore and was discharged on 14.10.2017.  The complainant has submitted two sets of claim documents for reimbursement of medical expenses incurred to the tune of Rs.3,45,604/- and Rs.30,402/- respectively on two different dates.  Each set of claim treated as individual claim due to the bills submitted falls under different plan period and covered under different policy number as stated above.

OP-3 further submitted that based on the available medical documents and as per the applicable policy conditions of the Group mediclaim policy of Huawei Technologies India Pvt Ltd : Parents, complainant’s mediclaim documents were verified by OP-3 medical team and found as under:

For the claim ID-1700557:- Treatment undergone is an unproven procedure and referred the claim to Insurer’s approval for further action on dated 08-November 2017.  Based on the approval received from the Insurance Company, we have repudiated the claim under the clause 4.13 “Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc”.  As per the group medical policy terms and conditions issued by the Oriental Insurance Company Ltd., to the complainant.

For the Claim ID-1760134:- Patient treated on an out patient basis which is not covered as per the policy terms and conditions and referred the claim to Insurer’s approval for further action on dated 31-December-2017.  Based on the approval received from the Insurance company, we have repudiated the claim under the clause 4.23 “Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, sex change or treatment which results from or is in any way related to sex change” as per the Group medical policy terms and conditions issued by the Oriental Insurance Company Limited and the repudiation letter has been sent by Oriental Insurance Company Ltd., to the complainant.

          OP-3 further submitted that OP-3 obligated to process the claim as per the terms and conditions of the policy issued by Oriental Insurance Company Limited after due verification of the submitted documents.  OP-3 processing the claims under the policy issued and has no privity of contract with the insured/complainant.  OP-3 is not party to this case.  There is no negligence and unfair trade on the part of OP-3.  Hence OP-3 prayed for dismissal of the complaint.

5. In the course of enquiry into the complaint, the complainant and the OPs.1, 2 & 4 have filed their affidavit reproducing what they have stated in their respective complaint and objections.  Complainant and OPs.1, 2 & 4 have submitted written arguments.  Complainant and OPs have produced certain documents.  We have heard the arguments of complainant and OPs and we have gone through the oral and documentary evidence of both parties scrupulously and posted the case for order.

6. Based on the above materials, the following points arise for our consideration;  

1. Whether the complainant has proved that there is deficiency in service on the part of the OPs, if so, whether complainant is entitled for the relief sought for?

2.  What order?

7. Our findings on the above points are as under:

Point No.1:  Negative

Point No.2:  As per the order below

REASONS

8. Point No.1:- On perusal of the pleadings, evidence and documents produced by both the parties, it is an admitted fact that, the complainant son was an employee of Huawei Technologies India Pvt. Ltd., and he had obtained a Group Mediclaim Policy from OPs vide policy bearing No.520000/48/2017/659.  The same was valid from 01.08.2017 to 23.10.2017 as per Ex-A3.  The contention of the complainant is that the doctor diagnosed that the complainant has been afflicted with “Metastatic Poorly Differentiated Urothelial Carcinoma” (cancer in the bladder) and the complainant opted for SPMF therapy at SBF Healthcare Private Limited from 17.09.2017 to 14.10.2017.  For the above said treatment the complainant spent Rs.3,00,000/-.  After taking treatment the complainant submitted a claim form along with documents to the OPs.  OPs have rejected the claim under clause 4.13 of the policy terms and conditions.

9. On perusal of the repudiation letter dated/Ex-A6 which reads here as under:

The denial clause/s with description is/are reproduced below for your ready reference:

Since the claim does not fall within the purview of the Policy terms conditions, we regret our inability to admit the claim.  If you have any other information or documents to substantiate admissibility the claim, please provide the same within 15 days of receipt of this letter.  If you are not satisfied with our denial reason, you may write to Grievance Redressal Cell of the The Oriential Insurance Co. Ltd at its policy issuing office, concerned Divisional Office, Concerned Regional Office or the Grievance Cell of the Head Office of the Insurance Company.  If you are not satisfied with the decision of the Grievance Cell/Dept of the Insurer, you may approach jurisdictional Insurance Ombudsman (located across 12 cities) and established by the Central Government for the redressal of grievances of Individual Policyholders.

10. Further, OPs submits that the complainant was suffering from cancer and he was advised chemotherapy but the patient refused the same.  Without expert doctor opinion the complainant himself taken a treatment for post SBMF therapy i.e., sequentially programmed magnetic field therapy which is excluding in the policy terms and conditions.  Hence the OPs have repudiated the claim. 

11. Further on perusal of letter dated 14.10.2017/Ex-A4 issued by Dr.V.G Vasishta, Founder and CEO SBF Healthcare and Research Center Private Ltd., which reads here as under:

History:

Patient is a known case of metastatic poorly differentiated urothelial carcinoma with multiple enlarged lymph nodes in aortocaval, preaortic and left aortic region.

CT guided biopsy confirmed urothelial carcinoma.  He was investigated with blood tests and a PET CT scan dated 04 Aug 2017, which showed enlarged prostate with high uptake, multiple enlarged lymph nodes in the aorto caval, pre aortic para aortic region.  He was advised chemotherapy but the patient refused the same. 

12. As per the said document, it is clear that the complainant was suffering from cancer and he has refused to take chemotherapy and then he has undergone the said SBMF therapy.

13. Complainant submits that several doctors advised that the remedy for alignment would be chemotherapy.  At that time the therapy for the recession of the cancer in the name of SBMF therapy found.  This treatment is not only non evasive and painless and it also cost the lesser financial burden to the complainant.  Due to age and health related reasons the chemotherapy was not visible.  Hence the complainant chosen to undergo SBMF therapy at SBF Healthcare for 28 continuous days.  The treatment was given by Dr.V.G Vasishta, who was an M.D in Radiology has conducted extensive research in this field.  The research and clinical trials indicated substantial relief to several patients.  In this regard publication in several National and International journals of repute.  Dr.V.G Vasishta has successfully treated hundreds of patients.  In this regard he has also got an ‘SUWARNA KARNATAKA RAJYOTSAVA AWARD’ by Government of Karnataka.  Further the similar issue was taken up for consideration by Hon’ble National Commission in R.P.No.2362/14 dated 23.02.2015 in the case of New India Assurance Co., Ltd., & Anr., v. Ishu Motwani was pleased to consider a similar matter wherein the Hon’ble National Commission has held that one hour treatment continuously for 21 days would be entitled for reimbursement.  Further the above said judgment para.7 of the order which reads here as under:

Brief perusal of the Policy shows that it is a Goodhealth Policy Certificate issued on 1.9.2012 to the insured who is 61 years of age.  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.  When SPMF Therapy is not specifically excluded, the act of the Opposite Parties in repudiating the claim on the ground that the treatment is similar to RFQMR without adducing any expert evidence to that effect or filing the affidavit of any doctor to evidence the same, amounts to deficiency of service.  

14. The said citation referred by the complainant is not applicable in the instant case.  The facts of the case is different from the present case.  In the instant case the complainant undergone the treatment for “Metastatic Poorly Differentiated Urothelial Carcinoma” (cancer in the bladder).  The complainant has not produced any documentary evidence to prove that “Metastatic Poorly Differentiated Urothelial Carcinoma” (cancer in the bladder) is clinically proved through SBMF therapy.  Therefore, we come to the conclusion that the said treatment taken by the complainant is clinically unproved which excluding the policy terms and conditions.  Hence the OPs have rightly repudiated the claim under clause 4.13 of the terms and conditions of the policy.  The OPs have acted strictly in accordance with the terms and conditions of the policy issued to the complainant.  Therefore there is no negligence or deficiency in service on the part of OPs in rejecting the claim of the complainant.  The complainant has failed to prove deficiency in service on the part of OPs.  Accordingly we answer the point No.1 in the negative.

          15. Point No.2: In the result, we passed the following:         

  O R D E R

The complaint filed by the complainant is dismissed.  Parties to bear their own costs.

Supply free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the open Commission on this 27^th day of November 2020)

Witnesses examined on behalf of power of attorney holder of complainant by way of affidavit:

Sri.Santosh Venugopal.

Copies of documents produced on behalf of complainant:

Witnesses examined on behalf of the OPs.1, 2 & 4 by way of affidavit:

Sri.R.S Arasu, who being Administrative officer.

Documents produced on behalf of Opposite Parties.1, 2 & 4:

Documents produced on behalf of Opposite Party-3:

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