1.       The present Revision Petition (RP) has been filed by the Petitioner against Respondents as detailed above, under section 21 (b) of Consumer Protection Act 1986, against the order dated 17.02.2022 of the State Consumer Disputes Redressal Commission Karnataka (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 60 of 206 in which order dated 18.11.2015 of  Bengaluru IV Additional District Consumer Disputes Redressal  Forum (hereinafter referred to as District Forum) in Consumer Complaint (CC) no. 1298 of 2013 was challenged, inter alia praying for setting aside the order dated 17.02.2022 of the State Commission.

2.       While the Revision Petitioner (hereinafter also referred to as OP No.2) was Respondent No.2 before the State Commission and OP No.2 before the District Forum, the Respondent No.1 ( hereinafter referred to as Complainant) was Appellant before the State Commisison and Complainant before the District Forum and Respondent No.2 was Respondent No.1 before the State Commission and OP No.1 before the District Forum.  For the sake of convenience, parties will also be referred to as they were arrayed before the District Forum.

3.       Notice was issued to the Respondents on 29.08.2022. Petitioner filed Written Arguments/Synopsis  on 29.01.2024.  Due to non appearance despite service, respondents was proceeded ex parte.

4.       Brief facts of the case, as emerged from the RP, Order of the State Commission, Order of the District Forum and other case records are that Complainant took ‘Reliance Healthwise Policy’ of the OP.  The complainant was experiencing severe pain in both knees joint, which curtailed her day to day living.  She decided to seek medical investigation by way of x-rays of knees, which revealed presence of Osteoarthritis in both knees.  Based on this, the medical advice was to undergo treatment using sequentially programmed magnetic field therapy (SPMF therapy) for 21 days consecutively at SBF Healthcare and Research Centre of which Wg. Cdr. Dr. V.G.Vasishta ( Retd) was the CEO.  During the treatment, the affected joints were treated using the SPMF therapy one hour everyday followed by Physiotherapy for ½ hours continuously for 21 days and the treatment has resulted in substantial relief from the pain.  She spent a total sum of Rs.1,40,000/- and same was paid to SBF Health Care and Research Centre by way of credit card of  Standard Chartered Bank.  Complainant submitted her claim for reimbursement of said amount, which was repudiated by the OPs on the ground that treatment was not inpatient treatment.  Being aggrieved, the Complainant filed CC before the District Forum and District Forum vide order dated 18.11.2015 dismissed the complaint of the Complainant. Being aggrieved, the Complainant preferred an appeal before the State Commission and State Commission vide order dated 17.02.2022 allowed the appeal of the Complainant. Therefore, the OP is before this Commission now in the present RP.

5.       Petitioner has challenged the said Order dated 17.02.2022 of the State Commission mainly on following grounds:

1. The State Commission has passed a non-speaking order and not dealt with the merits of the case and judgments cited by the State Commission nowhere supports their findings.

2. State Commission has not given any finding on the fact that respondent no.1 is suffering from pain in both knees for past four years, which  makes it evident that respondent no.1 was suffering from the said illness even before the present policy was issued and it was pre-existing disease and it is stipulated in the terms and conditions of the policy that  pre existing disease is covered from the 3^rd year of the policy after two continuous renewals of the policy. 

3. State Commission did not interpret the clauses of the terms and conditions of the insurance policy and complainant is not liable for the claim because she was never admitted to the hospital for a minimum period of 24 hours as required under the terms, conditions and schedule of the policy.

4. State Commission erred in interpreting the definition of ‘Day Care Treatment’ as bare perusal of same is evident to substantiate the fact that respondent no.1 does not fall under the said definition.

5. Respondent no.1 was under a contractual liability to give immediate note to Third Party Administrator and the Petitioner on the day of hospitalization / treatment . 

6. State Commission proceeded to set aside the findings of District Forum without giving the petitioner the right to be heard. 

6.       Heard counsel of Petitioner. On account of absence despite notice, Respondent were proceeded ex-parte.  Contentions/pleas of the parties, on various issues raised in the RP, Written Arguments, and Oral Arguments advanced during the hearing, and records of State Commission and District Forum are summed up below.

6.1. Counsel for the Petitioner repeated the points which are stated in para 5, grounds for challenging the order of the State Commission, hence the same are not being repeated here.

7.       Although, the copy of the repudiation letter was placed before the District Forum, the same has not been placed on record as part of the Revision Petition case file. As mentioned in the order of the District Forum, the claim has been repudiated by OP No.2 stating that claim of the complainant for management of ailment where hospitalization is less than 24 hours and also not falling under day care procedures listed in the policy under clause 2.2 of the policy.  Hospitalization not being for 24 hours or more is not in dispute.  Even as per the case of the complainant, based on the medical advice, she went for treatment using Sequentially Programmed Magnetic Field Therapy ( SPMF Theory). During the treatment, the affected joints were treated using SPMF therapy, one hour everyday, followed by Physiotherapy for ½ hours continuously for 21 days.  Hence, the main issue for consideration is whether the case of the complainant falls under clause 2.2., under which for day care treatment undertaken in hospital / nursing home, 24 hours hospitalization is not necessary.  This clause lists certain diseases which require hospitalization for less than 24 hours and hence are eligible for coverage under the policy. The District Forum observed that in the present case, the complainant was never admitted to hospital for minimum period of 24  hours as required under terms and conditions of the policy and also the treatment taken by the complainant is not given under the clause of day care treatment,  OP has rightly rejected the claim of the complainant and hence dismissed the complaint.  The State Commission allowed the appeal filed by the complainant and set aside the order of the District Forum observing as follows:

 “Learned counsel for appellant/complainant would submit that, this Commission in the case of Regional Manager, National Ins. Co. Ltd., V/s O.P.Kinger and another in Appeal No.2502/2010 on 03.08.2011, in similar case confirmed the order of the District Forum in Appeal filed by Insurance Company and on 20.06.2019 in yet another case in Appeal No.1251/2017 in the case between M/s Religare Health Ins. Co. Ltd., and another V/s Mrs Susan Gerishi Rajamani Mukthipudi also dismissed the appeal of Insurance Company. Thus, these two decisions of the Commission found support to the case of appellant herein and further to substantiate, learned counsel would relied on a decision in R.P.No.2362/2014 decided on 23.02.2015 in the case between New India Assurance Co. Ltd., and others V/s Ishu Motwani, wherein held; When SPMF therapy is not specifically excluded, the act of the OP 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, is aptly applicable to the facts of the case herein this appeal. It is therefore, followed by these three decisions, Commission of the view that dismissal of complaint raised by appellant herein has to be held contrary to the facts and law, liable to be set aside. Accordingly, Appeal No.60/2016 filed u/s 15 of the C.P Act, 1986 is hereby allowed. Consequently the impugned order dated 18.11.2016 passed in CC-No. 1298/2013 by IV Addl. District Consumer Disputes Redressal Forum, Bengaluru is set aside and directed respondent/OP to reimburse Rs.1,46,506 and do pay interest thereon @ 6% p.a from the date of repudiation and do pay cost of litigation at Rs.20,000/- within 60 days from the date of receipt of this order.”

8.       We have carefully gone through the condition 2.2 of the policy  as stated by the District Forum in para 10 of its order, which has been marked as Ex.R-1. This part of District Forum’s order is reproduced below :

“10.    The 2^nd OP has produced copy of terms and conditions of the policy issued at Ex.R1 wherein under clause 2.2, it is stated as under : Day care treatment undertaken in a hospital / nursing home on the recommendation of a medical practitioner for the following diseases, illness or injury which require hospitalization for less than 24 hours :

a.         Dialysis

b.         Chemotherapy

c.         Radiotherapy

d.         Eye surgery

e.         Dental surgery

f.          Lithotripsy ( kidney stone removal)

g.         Tonsillectomy

h.         Dilatation and curettage

i.          Cardiac Catheterization

j.          Hydrocele surgery

k.         Hernia Repair Surgery

l.          Surgeries procedures that require less than 24 Hours hospitalization due to advancement in technology and

In the said policy under heading Basic cover it is stated as under : ‘Insured person should have been hospitalized as an inpatient for a minimum period of 24 hours.  However in respect of the day care treatment  undertaken in a hospital / nursing home 24  hours hospitalization is not  necessary.”

9.       We have also gone through the policy document placed on record by the Petitioner / Insurance Company, which is available at page nos. 76-85 of the paper-book, but find that said policy document filed by the Insurance Company does not contain any clause 2.2. as  has been referred to by the District Forum in para 10 of its order as stated above.  It appears that either the Petitioner -   Insurance Company has filed a different policy document or incomplete document before this Commission than the one placed on record before the District Forum vide Ex.R-1.  Even if we go by clause 2.2. of said Ex.R-1 relied upon by the District Forum, we are of the view that list is perhaps not exhaustive but indicative in nature, which is evident from the last entry ‘l’ which states that “surgeries procedure that require less than 24 hours hospitalization due to advancement in technology”. We are of the view that treatment undertaken by the complainant / respondent herein viz. Sequentially Programmed Magnetic Field Therapy ( SMF Therapy) can be covered under the “procedures that require less than 24 hours hospitalization”.  It was held by Hon’ble Supreme Court in Canara Bank Vs. United India Insurance Co. Ltd. & Ors. (2020) 3 SCC 455 that “……..Insurance Policy must be read holistically so as to give effect to reasonable expectations of all the parties including the insured and the beneficiaries-  it must be interpreted in a commercially sensible manner- coverage clauses to be read broadly, and ambiguity, if any, to be resolved in favour of insured-exclusions to be read narrowly……..” 

10.     In view of the foregoing, we are of the view that District Forum went wrong in concluding that in accordance with condition no.2.2. of the policy, OP was justified in repudiating the claim.  Further, the Petitioner – Insurance Company ought to have placed on record correct and complete version of the policy in question which has clause 2.2 on the lines mentioned in para 10 of the District Forum’s order. We are in agreement with the findings of the State Commission and find no reason to interfere with the same.  Accordingly, we uphold the order of the State Commission.  Revision Petition is dismissed.

11.     The pending IAs in the case, if any, also stand disposed off.