PER SHRI. S.M. RATNAKAR – HON’BLE PRESIDENT
1) The Complainant has prayed that the Opposite Parties be directed to pay Rs.1,09,587/- with interest @ 18% p.a. from the date of filing of this complaint till its realization. It is also prayed that the Opposite Parties be directed to pay Rs.50,000/- as compensation for the mental agony and inconvenience caused to the Complainant and cost of Rs.25,000/- towards this complaint. The Complainant has also prayed Rs.10,000/- towards the correspondence, telephonic calls, etc. made to the Opposite Parties.
2) According to the Complainant, she has obtained the mediclaim policy issued by the Opposite Party No.1. The Opposite Party No.2 is the Regional Office of the Opposite Party No.1. The Opposite Party No.3 is TPA of Opposite Party Nos.1 & 2. The policy which is relevant for the present dispute was inforce from 01/07/2009 till 30/06/2010. The copy of the said policy is at Exh.‘A’. According to the Complainant, she was having pains in her knees since 2007-08 and she was unable to walk and it was difficult for her to do routine work because of such pains. The Complainant had taken medicines as advised by her family doctor and other doctors but she could not get much relief. The Complainant later on came to know about the treatment of Osteoarthritis called as Rational Field Quantum Magnetic Resonance “RFQMR” being offered by Bangalore based Company “Cartigine Health Care Pvt. Ltd.”. The said Health Care Service is having its centre of Mahakali Caves Road, Andheri (E), Mumbai – 93. The Complainant therefore, made enquiry with the said Bombay based centre known as SBF Health Centre. The Complainant also collected the information about RFQMR treatment on the website of the above centre. The Complainant then started taking treatment of Dr. Atul Gajare of the said centre. The copy of the treatment summary issued by Dr.Bramhachari & Dr. Gajare are at Exh.‘B’ & ‘C’ dtd.19/09/2009 & 15/01/2010 respectively. It is submitted that the Complainant had taken RFQMR treatment for continuous period of 21 days from 26/12/2009 to 15/01/2010 as mentioned in Exh.‘B’. As per the said treatment the Complainant was not required any hospitalization. The Complainant for the said treatment had paid Rs.1,09,587/-and also followed further physiotherapy treatment and medicines. It is submitted that Dr. Atul Gajare of SBF Health Care who had treated the Complainant had given discount of Rs.25,000/- out of the estimated bill of Rs.1,25,000/-. The Complainant was required to take medicines of the remaining amount of Rs.9,587/-. It is submitted that the treatment which the Complainant had taken is the technologically advance treatment. The Complainant thereafter, lodged the claim to the Opposite Party No.3 of Rs.1,09,587/- on 19/02/2010. The copy of the said claim form is at Exh.‘E’. It is submitted that the Complainant received rejection letter from the Opposite Party No.3 on 29/03/2010 by stating that the treatment which the Complainant had obtained was possible on OPD basis. Copy of the said letter is marked as Exh.‘F’. According to the Complainant, the rejection letter issued by the Opposite Party No.3 is wrong and improper as the Complainant obtained the treatment as per advice of the aforesaid doctors and had incurred the expenses for the said treatment to the tune of Rs.1,09,587/-. It is submitted that therefore, the Complainant is entitled for the reliefs claimed in para 1 of this order.
3) The Opposite Party Nos.1 & 2 contested the claim by filing written statement. It is contended that the Opposite Party No.3 has rightly repudiated the claim as the said treatment was possible on OPD basis. It is contended that the treatment obtained by the Complainant was not as per the terms and conditions of the policy which is at as Exh.‘A’. It is submitted that as per the certificate issued by SBF Health dtd.19/09/2009, the treatment obtained by the Complainant is day care treatment and was not required any hospitalization and therefore, it is not covered under the policy issued to the Complainant. It is denied that the Complainant had taken “RFQMR” treatment for continuous period of 21 days i.e. from 26/12/2009 to 15/01/2010. It is also denied that the Complainant had taken advance treatment as alleged. According to the Opposite Party Nos.1 & 2, as per Clause No.5.5, the Complainant did not submit the claim form within 30 days from the date of completion of treatment alongwith required documents. The Complainant has filed the claim with malafied intention to which she is not eligible as per the condition of the policy and the Opposite Party No.3 has rightly rejected the claim. It is denied that the Opposite Parties are guilty of deficiency of service and unfair trade practice. The Opposite Parties have denied the claim made in the complaint. The Opposite Parties have thus, submitted that the Complainant is not entitled to any reliefs and the complaint is liable to be dismissed with cost.
4) The Complainant has filed her affidavit of evidence. The Opposite Party has filed affidavit of J.S. Tonk, Regional Manager. Both the parties filed their written arguments. We heard oral arguments of Smt. S.D. Gandhi, Ld.Advocate for the Complainant and Shri. K.C. Sanil, Ld.Advocate for Urmila Sanil Advocate for the Opposite Party Nos.1 & 2. We have perused the documents.
5) While considering the claim made by the Complainant in this complainant, it is necessary to be seen that whether the Opposite Parties have rightly rejected the claim lodged by the Complainant or not. The Opposite Party No.3 by its letter dtd.10/06/2010 repudiated the claim for the following reasons –
“On scrutiny of the documents submitted, we noticed that the patient had taken treatment OESTEO Arthritis. We further noticed that the treatment is possible on OPD basis. According to the policy sub limits, the expenses for treatment possible on OPD are payable by the insurance. Hence, the claim stands repudiated.”
The contention raised by the Opposite Parties that as the Complainant could have taken for Osteo Arthritis on OPD basis and the same is not admissible in view of the policy sub-limits, it is required to be proved by the Opposite Parties. In this case the Opposite Party No.3 who had informed the Complainant that for the aforesaid reason her claim is repudiated has not appeared before this Forum and contested the claim made in the complaint. We therefore, hold that the claim made in the complaint goes unchallenged for non appearance of the Opposite Party No.3. The Opposite Party Nos.1 & 2 have not communicated or made any correspondence regarding the claim lodged by the Complainant. From the certificate issued by Dr. Atul Gajare at Exh.‘C’, it appears that he had made investigation through certain tests as mentioned in the certificate. The said doctor who is MS. Orthopedic has specifically certified that the Complainant was advised for treatment using Quantum Magnetic Resonance (QRM Therapy) for 21 days consecutively. During this treatment the affected joints were exposed to radiofrequency beams for 1 hour followed by Physiotherapy for half hour and observation for one and half hour, her total stay at the centre was three hours everyday. On the first day the treatment the patient was admitted for eight hours tentively for blood investigation treatment, rehab exercises, pain management and observation. Considering the said certificate placed on record by the Complainant, it appears that the treatment which was obtained by the Complainant was needed specialize infrastructural facilities and the same were only available in hospital or health care centre. From the certificate of Dr. Gajare it is brought on record by the Complainant that due to technological progress the Complainant was not required to be admitted for more than 24 hours but the treatment which she had obtained was required to be taken 3 hours every day for 21 days. The Complainant has thus, brought on record that she had undergone the treatment in SBF Health Care Centre for more than 24 hours from 26/12/2009 to 15/01/2010. Considering the nature of the treatment we find that as the Opposite Parties have not brought on record that the treatment obtained by the Complainant was of a general nature and the same could have been obtained only as out door patient. We therefore, hold that the objection raised by the Opposite Parties for rejecting the claim on the aforesaid ground it totally illegal and improper. The other objection raised by the Opposite Parties under clause 5.5 in our view also cannot be accepted as legal and proper as the Complainant had taken the treatment upto 15/01/2010 and she had submitted the claim form on 19/02/2010 i.e. just after 34 days of completion of treatment. From the certificate issued by Dr. Gajare at Exh.‘A’ to ‘C’ it appears that the Complainant was advised to take vitamins and follow diet restriction for three months. Thus, it appears that the treatment of the Complainant was also continued after 15/01/2010. The attitude of the Insurance Companies rejecting the claim on the point of delay has been deprecated by Insurance Regulatory and Development Authority by its circular dtd.20/09/2011. We thus, hold that the submissions made by Shri.K.C. Sanil Advocate for the Opposite Party No.1 & 2 cannot be accepted as legal and proper for rejecting the claim in view of not complying the clause 5.5 of the policy.
6) The claim made in such type of cases has been allowed in various cases by this Forum as well as by other Consumer Forums. The said cases are as under -
1) CC No.208/2008, Indira C. Patel V/s. United India Insurance Co. Ltd., decided by South District Consumer Forum, Mumbai, on
31/10/2009.
2) CC No.231/2010, Rajesh Nambiar V/s. National Insurance Co. Ltd., decided by South District Consumer Forum, Mumbai, on 05/10/2011.
3) CC No.220/2010, Arun G. Bharal V/s. Oriental Insurance Co. Ltd., decided by Suburban District Consumer Forum, Mumbai, on
31/05/2012.
4) CC No.618/2010, Kumar Gupta V/s. United India Insurance Co. Ltd., decided by Suburban District Consumer Forum, Mumbai, on
05/04/20213.
5) CC NO.73/2011, Kishori Karkhanis V/s. Reliance General Insurance Co. Ltd., decided by Central District Consumer Forum, Mumbai on
20/08/11
In all the aforesaid case the Insurance Companies have raised similar objections and some more objections such as, not admitting the patient in the hospital for continuous period of treatment or more than 24 hours, etc., however, the said objections were turned down by the judicial decisions. We therefore, hold that the Opposite Parties have wrongly repudiated the claim.
The Opposite Parties have not denied that the Complainant had incurred an expenditure of Rs.1,09,587/- for her treatment at SBF Healthcare Centre Mumbai. The Complainant had also produced the bills issued by the said Health Care Centre and medicine bills in our view therefore, the Complainant is entitled for the amount of Rs.1,09,587/- from the Opposite Parties with interest @ 6% p.a. from 19/02/2010 till its realization. As the Opposite Parties have denied the claim without any justification and adopted unfair trade practice as discussed above. The Complainant has claimed compensation to the tune of Rs.50,000/- in our view the said amount is much exorbitant and an amount of Rs.7,500/- would be justified for the mental agony and inconvenience suffered by the Complainant. The Complainant would be entitled to cost of Rs.5,000/- towards this complaint and the expenses, if any incurred by her for persuasion of the claim with the Opposite Parties. In the result we passed the following order –
O R D E R
i. Complaint No.124/2012 is partly allowed against Opposite Parties.
ii. The Opposite Parties are directed to pay Rs.1,09,187/- (Rs. One Lac Nine Thousand One Hundred Eighty Seven Only) with
interest @ 6% p.a. from 19/02/2010 till its realization to the Complainant.
iii. The Opposite Parties are directed to pay Rs.7,500/-(Rs. Seven Thousand Five Hundred Only) as compensation to the
Complainant towards mental agony and inconvenience caused to the Complainant and cost of Rs.5,000/- (Rs. Five
Thousand Only) towards this proceeding.
iv. The Opposite Parties are directed to comply the aforesaid order within one month from the date of receipt of this order.
ix. Certified copies of this order be furnished to the parties.
