O R D E R<br /> <br /> <br /> SRI.D. KRISHNAPPA, PRESIDENT:<br /> <br /> The brief facts of the complaint filed by the complainant against the Ops are that, she had a mediclaim policy with Op No.2 for the last 6 years without a break and was valid up to 30/09/2009. That she suffered severe pain in her knees then she consulted Dr. K.P. Loknath Kumar for treatment, who on thorough investigation advised and recommended for RFQMR therapy for 21 days and she took treatment from 13/07/2009 till 02/08/2009 at Care Plus Medical Centre, Bangalore. Her condition was improved and she incurred total expenditure of Rs.1,25,000/- and she paid that amount to the doctor. Then she made a claim with Op No.1 along with necessary documents on 17/08/2009 and also sent reminders on 24/08/2009 for reimbursing all the amount but the second Op vide letter dated 15/09/2009 rejected the claim on the ground that RFQMR therapy is not payable under the policy. Then she made a demand with Op No.2 through his letter dated 14/10/2009, who refused the claim and thus has contended unilateral refusal by the Ops is not proper and therefore, has prayed for a direction to Ops to reimburse the medical expenditure with damages and interest.<br /> <br /> 2. Op No.1 who is duly served with the notice, remained absent is set ex-parte. OP No.2 has appeared through his advocate and filed version admitting issue of policy which was valid from 31/08/2008 to 30/09/2009 but denied that the complainant was suffering from knees pain. That the claim is governed by the terms and conditions of the policy and stated that expenses incurred for taking RFQMR therapy is not payable under the said policy. That the treatment of the complainant did not follow the essential requirement and stated that reimbursement required hospitalization and complainant has not taken treatment in a hospital as it was only a medical care centre. The complainant has taken treatment as an out patient, exposing to beam rays as per the records. Treatment must have been taken at an institution in India established for the indoor treatment and minimum 24 hours hospitalization is required. But the complainant was not hospitalized as such, the claim of the complainant is repudiated and further contended that medical center where the complainant has taken treatment had no bed facility for treating as in patient and admitting the claim received by them, justified their action in rejecting the claim and thereby have prayed for dismissal of the complaint.<br /> <br /> 3. In the course of enquiry into the complaint, the complainant and the Regional Manager of the second Op have filed their affidavit evidence reproducing what they have stated in their respective complaint and version. The complainant along with the complaint has produced copy of a policy, copy of repudiation letter and copies of two letters she had addressed to Ops with copies of hospital records. Op No.2 has produced a copy of an award passed by Insurance Ombudsman on a claim of different claimant. We have heard the counsel for both parties and perused the records.<br /> <br /> 4. On the above contentions, following points for determination arise.<br /> <br /> 1. Whether the complainant proves that Ops have caused deficiency in their service in repudiating the claim of the reimbursement towards medical expenditure?<br /> 2. To what relief the complainant is entitle to?<br /> <br /> <br /> <br /> 5. Our findings are as under:<br /> <br /> Point No.1 : In the affirmative in part<br /> Point No.2 : See the final order<br /> <br /> REASONS<br /> <br /> 6. Answer on point No.1: It is not in dispute that the complainant had taken a mediclaim policy called good health policy certificate and it was valid from 01/01/2008 to 30/09/2009. Complainant has claimed that because of pain in her knees, she took treatment from one Dr. K.P. Loknath Kumar and she was under therapy called RFQMR for 21 days from 13/07/2009 to 02/08/2009 and incurred total expenditure Rs.1,25,000/-. The claim made by the complainant to Op came to be repudiated by the first Op who is a third party administrator on the ground that on the claim documents submitted, the claim is medically repudiated as RFQMR therapy is not payable by insurance company. The complainant questioning this repudiation has come up with this complaint.<br /> <br /> 7. Op No.2, the insurance company in their version and also affidavit evidence stated as if policy covers only hospitalization expenditure as an in patient and as per the definition of the hospital as given in the policy. The medical centre where the complainant has taken treatment did not have the facility of admission as in patient, that the complainant has been treated as out patient. That in order to reimburse the medical expenditure minimum 24 hours hospitalization is required and in this case since the complainant was not at all an in patient, the condition of the policy do not allow the reimbursement. The counsel for the second Op by referring to certain clauses of the conditions of the policy particularly condition No.3.2 submitted that the complainant must have taken treatment in a hospital where there must be minimum 10 or 15 beds available for in patient, that hospital must be having fully equipped operation theater and with all round the clock fully qualified nursing staff must be in the employment and thereby submitted, these facilities were not there in the Centre where the complainant has taken treatment and therefore, justified the action of the Op in repudiating the claim of the complainant.<br /> <br /> 8. We should bear in mind, the vast researches and developments that have taken place in the medical field in treating various types of diseases with such advanced treatments wherein several diseases are being treated without hospitalization and in short period. Advanced medicines, surgeries and equipments have changed the primitive line of treatment and with that innovative methods of treatment it is not justified for this Op to take contention that 24 hours hospitalization is a must to reimburse the medical expenditure and further insisting that treatment must have been taken in a hospital where there must be minimum 10 to 15 beds facilities, operation theatre with round clock qualified doctors and nurses. In our view it is an unreasonable restriction on the insured. Depending upon the nature of the disease and expertiseness available for treating such disease one may treat the disease in the clinic itself without any need for hospitalization and if reimbursement of the expenditure for that disease is admissible under the conditions of the policy, claim cannot be rejected for the reasons of the patient was not an inpatient and has not taken treatment in a hospital where bed facilities and operation theatre was not available. Even condition No.3.2 makes an exception which contain a note reads as under:<br /> <br /> “In case of Ayurvedic/Homeopathic/Unani treatment condition No.3.2 (b) is not made applicable, similarly in case of Day Care Centre condition No.3.2 (a) is not applicable”. <br /> <br /> That means, if an insured take treatment from an Ayurvedic/Homeopathic/Unani hospital or doctor that hospital need not be equipped with any operation theatre of its own. Similarly, if an insured takes treatment in a Day Care Centre it need not be a hospital and it need not contain inpatient beds. Therefore, this is an exception which goes to the aid of the complainant who has taken treatment for her knees pain in a Care Plus Centre which it is said to be a centre for treating Osteoarthritis. Complainant has stated after availing treatment from that Care Plus she is finding relief from her pain. Therefore, the note given to condition No.3.2 of the conditions of the policy makes an exception and therefore, the contention of the Ops and arguments of the counsel for Op No.2 that the place where the complainant has taken treatment was lacking all the parameters cannot be accepted.<br /> <br /> 9. Op No.1 as found from the letter of repudiation except stating that claim is not payable has not elaborated the reason as to why is not payable. What we mean to say is, it is not the case of the opponents that the treatment availed by the complainant either is excluded under the conditions of the policy or fall within the exclusions of the policy conditions. The Ops except with a vague denial have not assigned the ground on which the claim is repudiated by referring to any of the conditions of the policy. Even other wise, as stated above, when the Op has not denied the treatment taken by the complainant in a medical care centre through innovative method and gets the relief, it is not for the Ops to insist upon that the insured must have got admitted as an inpatient and taken treatment in a hospital as stated by them. The ground of repudiation in our view is therefore untenable and has to be held as nothing but the deficient act of the Ops.<br /> <br /> 10. The complainant in support of her case has produced a certified copy of the order passed by II Additional District Consumer Forum in complaint No.599/09 and her counsel argued that in similar set of case for the similar ailment, the forum has granted a relief. The counsel for the complainant has also relied upon another decision of the same forum in complaint No.2387/09, the said forum by relying upon the finding of insurance ombudsmen of Kolkata has granted relief to the complainant. The facts of the case under reference and facts of the complaint in our hand are similar. As such, the complainant in our view is entitled for the relief. The counsel for the second Op has produced a copy of the award of insurance Ombudsmen of Chennai passed in award No.34/2009-2010, in this award the Ombudsmen while denying the claim of the insured for treatment of RFQMR has held that repudiation of the claim of the complainant for reimbursement cannot be faulted and dismissed the complaint. But for the reasons we have assigned above and also by referring to the findings of the Kolkata Ombudsmen relied upon by the II Additional District Consumer Forum, Bangalore we hold that repudiation of the claim of the complainant is not proper and that amounts to deficiency in their service.<br /> <br /> 11. As found from the policy limit, the complainant got mediclaim policy for Rs.50,000/- only where as the complainant claimed reimbursement of Rs.1,25,000/- which exceeds the policy limit. Therefore, complainant is entitled for reimbursement of Rs.50,000/- only and to that extent the complaint deserves to be allowed. With the result, we answer point No.1 in the affirmative in part and pass the following order.<br /> <br /> O R D E R<br /> <br /> Complaint is allowed in part. <br /> <br /> Ops 1 and 2 are jointly and severally held liable to reimburse the medical claim of the complainant partially and are therefore, directed to pay Rs.50,000/- to the complainant within 60 days from the date of this order failing which they shall pay interest @ 9% pa from the date of the claim of the complainant that is 17/08/2009 till the date of payment.<br /> <br /> Ops 1 and 2 shall pay cost of Rs.3,000/- to the complainant. <br /> <br /> Dictated to the Stenographer. Got it transcribed and corrected. Pronounced in the Open forum on this the 15th September 2010.<br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />