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

1)        By this complaint the Complainants have prayed an amount of Rs.1,35,230.29 towards the medical expenditure and Rs.1,00,000/- towards the hardship and agonies caused to the Complainants and cost of Rs.15,000/- of this proceeding.

2)        According to the Complainants, they had obtained Individual Mediclaim Policy for the period 07/03/2010 to 06/03/2011 as per the document filed at Exh.‘C-1’.  It is submitted that in the beginning of the year 2010-11, the Complainant No.1 started pains in the knees diagnosed to be Osteoarthritis.  The Complainant No.1 in view of the article published in Maharashtra Times in June, 2010 decided to obtain treatment for the knee joint pains without any surgery by QMR Therapy.  The Complainant No.2 accordingly informed the Opposite Party No.2 that the above treatment would be obtained by the Complainant No.1. The copy of the said letter is at Exh.‘C-3’.  Accordingly the Complainant No1 obtained the treatment from SBF Healthcare Pvt. Ltd. for the first phase of 21 consecutive days and it was completed on 11/08/2010.  The Complainant No.2 wrote letter to the Opposite Party No.2 with the copy to the Opposite Party No.1 raising interim claim of Rs.1,25,000/- for the first phase treatment and also informed when the second phase treatment would be started and communicated that the claim in respect of second phase would be submitted after 3 months from 11/08/2010. The Complainant No.2 accordingly submitted the necessary documents with Exh.‘C-4’ with Opposite Party No.2. The Opposite Party No.2 however, rejected the claim lodged by the Complainant as per letter dtd.16/08/2010 which is at Exh.‘C-5’.  It is submitted that in view of the correspondence made by the Complainant No.2 the Opposite Party No.2 vide letter dtd.21/09/2010 forwarded Head Office circular of Opposite Party No.1 dtd.07/09/2009.  The copy of the said letter and the circular are at Exh.‘C-7’.  It is submitted that the Complainant No.2 made several correspondence for allowing the claim lodged by him for the treatment provided to Complainant No.1 to the Opposite Parties.  However, the Opposite Parties did not pay any heed to the correspondence made by the Complainant No.2.  The Complainants therefore, made prayer for grant of reliefs as mentioned in para 1 of this order. 

3)        The Opposite Party No.1 filed written statement and contested the claim lodged by the Complainants.  It is contended that there is no deficiency in service on the part of Opposite Party No.1 and therefore, the Complainants are not entitled for any reliefs.  It is submitted that the Complainant No.1 lodged claim form Rs.1,35,230.29 paise towards the reimbursement of the expenses incurred for treatment called Quantum Magnetic Resonance (QMR) Therapy for Osteoarthritis at SBF Healthcare Pvt. Ltd.  It is contended that the claim was not payable as per the Health Policy for the following reasons –

            1.  SBF Healthcare are not registered as hospital and does not meet the definition of hospital.

            2.  The treatment does not require hospitalization and the duration of the treatment is less than an hour.

3.      It does not fall under the day care procedure.

4.      This is still and experimental and unproven system of treatment as evidence in their website. 

It is contended that all the treatment given to the Complainant No1. was related to Naturopathy treatment which falls under exclusion clause 4.13 of medical policy.  It is the case of the Opposite Party that the claim documents submitted by the Complainants were thoroughly scrutinized and thereafter the claim was repudiated as treatment QMR is experimental, unproven, non-standard treatment as the Complainant No.1 was not hospitalized but was treated on OPD basis therefore, the claim was not admissible under the condition No.2 of the policy.  It is submitted that the claim is not maintainable as per the terms and conditions of the insurance policy.  It is contended that there is no cause of action and deficiency of any service on the part of the Opposite Parties, the complaint is therefore, liable to be dismissed.  The Opposite Party No.1 parawise denied all the allegations and submitted that the complaint be dismissed with cost.

4)        The Complainant No.2 filed his affidavit.  The Opposite Party No.1 filed affidavit of D.K. Gupta, the authorized signatory of the Opposite Party No.1.  Both the parties filed their written arguments.  Both the parties filed the documents in support of their contentions. We heard Shri. A.K. Karandikar, Ld.Advocate for the Complainants and Smt. Asita Parmar, Ld.Advocate for the Opposite Party No.1.  We have perused the documents relied by both sides.

5)        While considering the claim made in this complaint it is necessary to be seen that as the Complainant No.1 has obtained the treatment at SBF Healthcare for server Osteoarthritis and she availed the treatment i.e. Quantum Magnetic Resonance Therapy which is as per the Opposite Party is an experimental and unproven treatment.  The burden lies upon the Opposite Parties to prove that the treatment obtained by the Complainant No.1 is excluded under Clause No.4.13 of the terms and conditions of the policy.  In policy clause 4.13 is shown as Naturopathy treatment.   In Condition No.2.1 it has been mentioned that hospital or nursing home should be registered with local authorities and it should be under the supervision of a registered and qualified medical practitioner. The Complainant has produced on record the document at page 41 with the complaint, showing treatment summary of Complainant No.1. The said document appears to have been issued by Dr. Atul Gajare, MS(Ortho) Consultant Orthopedic Surgeon, SBF Healthcare. Thus, the treatment which was obtained by the Complainant No.1 appears to have been obtained at the Healthcare Centre which is under the supervision of a registered and qualified medical practitioner is proved by the Complainants.  The Opposite Party no.1 has not brought on record as to what treatment is consist of Naturopathy. From the treatment of summary document placed on record at page 41 it also appears that the Complainant No.1 was advised for treatment using QMR therapy for 21 days consecutively and during the said treatment the affected joints were exposed Radio frequency beams for 1 hour followed by physiotherapy for an ½ hour and observation for 1 ½ hour, the total stay of the Complainant No.1 at the centre was 3 hours.  In the said treatment of summary document it is also mentioned that on the first day of treatment the patient was admitted for 8 hours tentatively for blood investigation, treatment rehab exercises, pain management and observations. Thus, in our view as the Complainant No.1 had obtained the treatment for more than 80 hrs. at SBF Healthcare.  The grounds for which the Opposite Parties have rejected the claim cannot be considered as legal and proper.  The Opposite Parties have not disputed that the Complainant No.1 has not obtained QMR treatment at SBF Healthcare for server Osteoarthritis to her both knees and she has incurred expenditure to the tune of Rs.1,25,000/- as per bill filed at page 42 with the complaint. The additional claim made of Rs.10,230.29 by the Complainants is not proved by any document.  The Complainant No.1 is thus, entitled to Rs.1,25,000/- only.  The Complainant has also produced on record copies of order passed by Ombudsman, Kolkata in the case of Prabir Kumar Chatterjee V/s. The New India Assurance Co. Ltd., dtd.19/06/2009 and the decision of this Forum in the case of Mrs. Indira C. Patel V/s. The United India Insurance Co. Ltd. in C.C.208/2008, decided on 31/10/2009. In the said case also the Opposite Party No.1 had raised similar objections. The said objections were turned down by various judicial decisions such as in CC No.231 of 2010 in the case of Rajesh Nambiar V/s. National Insurance Co. Ltd. decided on 05/10/2011 by this Forum as well as in CC No.221 of 2010 decided on 14/08/2013 in the case of Sanyuktaben G. Shah V/s. New India Assurance Co. Ltd. and in the Case Nos.335-336 of 2010 of Usha Majmudar V/s. New India Assurance Co. Ltd., decided on 07/12/2013 as well as in so many other cases not only by this Forum but the Additional District Consumer Forum Bangalore, in CC. No.599/2009 Sunita Ahuja V/s. The New India Assurance Co. Ltd.,dtd.19/06/2009 and also by the decision of Central Mumbai District Forum as well as Mumbai Suburban District Forum.  Thus, in our view the submission made by the Opposite Party No.1 through Smt. Asita Parmar for rejection of the claim in view of the clauses relied by the Opposite Parties cannot be accepted.  In our view the genuine claims are not expected to be rejected on technical grounds as contended by the Opposite Party No.1 in this case.  In our view the Complainant No.1 is therefore, entitled to an amount of Rs.1,25,000/- from Opposite Parties towards the medical expenditure which she had incurred for the QMR treatment to her both knees.  We also hold that as the Opposite Parties have denied the claim on technical grounds and adopted unfair practice while repudiating the claim, the Complainant No.1 is entitled for compensation of Rs.10,000/- towards mental agony and hardship caused to her.  TheComplainant No.1 is also entitled to interest @ 6% p.a. from 16/08/2010 on the aforesaid amount of Rs.1,25,000/- till its realization.  The Complainant No.1 is also entitled for cost of Rs.5,000/- towards this proceedings from the Opposite Parties. In the result we pass the following order –

O R D E R

                     i.       Complaint No.05/2011 is partly allowed against the Opposite Parties.

             ii.      The Opposite Parties are directed to pay Rs.1,25,000/- (Rs. One Lac Twenty Five Thousand Only) with interest @ 6% from 

                      16/08/2010 till it’s realization to the Complainant

                    iii.     The Opposite Parties are directed to pay compensation of Rs.10,000/- (Rs. Ten Thousand Only) toward mental agony and hardship

                             caused to the Complainant and Rs.5,000/-(Rs. Five Thousand Only) towards this proceeding to the Complainant.

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

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