Ex-P A R T E O R D E R

PER SHRI. S.M. RATNAKAR – HON’BLE PRESIDENT

1) By this complaint the Complainant has prayed that the Opposite Parties be directed to pay Rs.1,37,319/- with interest @ 18% p.a. from the date of payment made by the Complainant to SBF Healthcare Pvt. Ltd. or from the date of filing of this complaint till its realization as deemed fit by this Forum. The Complainant has also prayed for grant of compensation of Rs.25,000/- towards mental agony and inconvenience caused to the Complainant and cost of Rs.5,000/- towards correspondence and conveyance and Rs.25,000/- towards the expenses of professional charges and fees incurred by the Complainant for engaging service of advocate towards this complaint.

2) According to the Complainant, the Opposite Party No.1 issued the mediclaim policy to the Complainant. The Opposite Party No.2 is third party claim settlement administrator of Opposite Party No.1. It is submitted that mediclaim policy covers risk and benefits of medical treatment of insured. The Complainant had obtained mediclaim policy of Opposite Party No.1 since many years and the relevant policy was inforce from 24/10/2012 to 23/10/2013 under which the sum insured was Rs.2,00,000/-. The copies of the mediclaim policy are marked as Exh.‘A’.

3) According to the Complainant, he was feeling pain in his knees which increased day by day. Due to the said pain in knees he was not able to do his routine work with concentration. The Complainant had taken the advice of Doctors who suggested him to undergo knee transplant surgery for both the knees which was costing about Rs.4.50 to Rs.5.00 Lacs. It is submitted that the Complainant came to know about non evasive treatment of Osteoarthritis called Sequential Programmed Magnetic Field (SPMF) which was originally known as Quantum Magnetic Resonance (QMR) therapy being offered by Bangalore based Company “Cartigen Health Care Pvt. Ltd.” having its Mumbai branch known as SBF Health at Mahakali Caves Road, Andheri (E), Mumbai – 93. The Complainant made enquiry at the above centre and also got information about the above treatment on its website. The Complainant was satisfied with the result of other patients and approached to SBF Health Care Andheri.

4) It is submitted that he had taken advice of Dr. Atul Gajare at the above centre and had taken decision to go for the treatment referred above at the above Health Care Centre. The Complainant was admitted on 10/12/2012 for taking SPMF treatment for the period of 21 days consecutively from 10/12/2012 and was discharged on 30/12/2012. According to the Complainant, during the treatment the affected joints were exposed to sequentially programmed magnetic field for one hour and followed by Physiotherapy for one hour and observation for one hour. The total stay everyday during the above treatment period was about 3 ½ hrs. per day. On the first day of treatment the Complainant was admitted for 8 hrs. tentatively for blood investigation treatment, rehab exercise pain management and observation. The summary report of the treatment given to the Complainant dtd.05/12/2012 is at Exh.‘B’. It is submitted that during the period of treatment the Complainant had intimated the Opposite Parties by e-mail on 22/12/2012. The copy of the said e-mail is at Exh.‘C’. It is alleged that for taking the treatment the Complainant had paid Rs.1,25,000/- to SBF Health Care Centre as per bill dtd.27/12/2012 and incurred expenses of Rs.12,319/- for medicines. The Complainant had incurred total medical expenses of Rs.1,37,319/- for the aforesaid ailment. The copies of the bills of SBF Health Centre and medical bills are marked as Exh.‘D’. The Complainant submitted claim form to the Opposite Party No.1 as per Exh.‘E’. Thereafter, the Opposite Party No.2 by letter dtd.24/01/2013 called upon the Complainant to submit certain documents and accordingly the Complainant submitted the documents to the Opposite Party No.1 on 12/02/2013. The copies of the said letters are marked as Exh.‘F’. It is alleged that the Opposite Party No.2 by letter dtd.22/02/2013 rejected the claim for the reasons mentioned in the said letter. The copy of the said letter is marked at Exh.‘G’. It is alleged that the claim of the Complainant being genuine was required to be reimbursed by the Opposite Parties. The reasons for rejection of the claim are absurd, unjustified and illegal. The Complainant has given all the details of taking such treatment by prominent persons and the information about the treatment and how it covered under the terms of the policy. The Complainant has alleged that due to rejection of claim the Complainant is entitled for compensation. The Complainant has thus, prayed for the reliefs as mentioned in para 1 of this order.

5) The Opposite Parties No.1 & 2 though served remained absent. The complaint therefore, proceeded ex-parte against the Opposite Parties. The Complainant has filed his affidavit of evidence and the written argument in support of the complaint. The advocate for the Complainant Smt. S.D. Gandhi submitted oral argument and submitted that in view of the earlier decisions of this Forum and other Forums the Complainant is entitled for the reliefs as claimed.

6) We have gone through the documents relied by the Complainant and the decisions relied by the Complainant in the following cases –

The Advocate for the Complainant also relied and filed the copies of the orders passed by various Ombudsman against the Insurance Companies for the treatment in question. In our view in the aforesaid decisions all the objections raised by the Opposite Parties in the repudiation letter issued to the Complainant at Exh.‘F’ and ‘G’ have been considered on all its merits and it is held that the reasons given by the Opposite Parties are devoid of merits. We therefore, hold that as the Opposite Parties remained absent in this complaint and the case made out by the Complainant has not been challenged by them, the Complainant is entitled for the medical reimbursement to the tune of Rs.1,37,319/- from the Opposite Parties. The Complainant has claimed compensation of Rs.25,000/- towards mental agony and harassment, we find that the said claim is exorbitant and an amount of Rs.8,000/- would be justified on that count. The Complainant has prayed Rs.5,000/- towards the conveyance and correspondence but no proof has been produced by the Complainant, we therefore, hold that the said claim cannot be granted. The Complainant has prayed Rs.25,000/- towards the expenses of professional charges for engaging service of advocate for this complaint, we find that an amount of Rs.5,000/- would be justified on this count. The Complainant has claimed interest @ 18% p.a. on the medical expenses incurred by him either from the date of amount incurred by him or from the date of this complaint, we find that the Opposite Parties are liable to pay interest on amount of Rs.1,37,319/- @ 9% p.a. from the date of filing of this complaint i.e. 17/07/2013 till its realization. In the result the following order is passed –

O R D E R

1. Complaint No.160/2013 is partly allowed against Opposite Parties.

2. The Opposite Parties are directed to pay Rs.1,37,319/- (Rs. One Lac Thirty Seven Thousand Three Hundred Nineteen Only) with interest @ 9% p.a. from 17/07/2013 i.e. the date of filing of complaint till it’s realization.

3. The Opposite Parties are directed to pay Rs.8,000/- (Rs. Eight Thousand Only) to the Complainant for causing mental harassment by rejecting the claim lodged for his medical treatment and cost of Rs.5,000/- (Rs. Five Thousand Only) towards this complaint.

4. The Opposite Parties are directed to comply with the above order within one month from the date of service of this order.

5. Certified copies of this order be furnished to the parties.