Karnataka

Bangalore 4th Additional

CC/194/2018

Smt Prabha Devi.K.P, - Complainant(s)

Versus

The Authoritized Signatory, Royal Sundaram General Insurance Company Limited, - Opp.Party(s)

09 Jan 2020

ORDER

Complaint Filed on:06.02.2018

Disposed On:09.01.2020

                                                                              

BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

 

 

 

 

 

09^thDAY OF JANUARY 2020

 

PRESENT

SMT.PRATHIBHA. R.K., BAL, LLM - PRESIDENT

SMT.N.R.ROOPA, B.A., LLB, MEMBER

 

 

COMPLAINT No.194/2018

 

 

COMPLAINANT	Smt.Prabha Devi K.P, W/o Suresh Kumar M.B, Aged about 48 years, R/a No.55, 3rd Cross, Akkalappa Layout, Ramamurthy Nagar, Bangalore – 560 016.   Advocate – Sri.Arvind Kaushik.       V/s
OPPOSITE PARTies	1) The Authorized Signatory, Royal Sundaram General Insurance Company Ltd., VishranthiMelram Towers, No.2/319, Rajiv Gandhi Salai (OMR) Karapakam, Chennai – 600 097.   2) The Authorized Signatory, Royal Sundaram General Insurance Company Ltd., No.298, 38th Cross Road, 4th Block, Jayanagar, Bengaluru – 560 011.   Advocate – Sri.Channabasappa S.N

 

ORDER

 

SMT.PRATHIBHA. R.K., PRESIDENT

 

The complainant has filed this complaintU/s.12 of the Consumer Protection Act, 1986against Opposite Parties (herein after referred as OPs) with a prayer to direct OPs to clear and reimburse the legitimate claim of Rs.1,25,000/-, Rs.20,000/- towards mental agony, trauma and hardship and Rs.20,000/- towards cost of legal expenses together with interest @ 16% from the date of repudiation.

 

2. The brief allegations made in the complaint are as under:

 

 

Complainant availed “Health Benefit Plus Insurance” policy bearing No.SL00032564000107 from OP.  The complainant submitted that complainant was suffering from pain in both knee joints which practically curtailed her day to day living.  The complainant seek medical investigation by way of X-rays of knees (AP & Lateral View) which revealed presence of Osteoarthritis in both knees.Based on the medical advice was to undergone the 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.GVasishta (Retd) is the C.E.O.  During the treatment the affected joints are treated using the SPMF therapy, one hour everyday followed by Physiotherapy for ½ hour continuously for 21 days.  The treatment afforded has resulted in substantial relief from the pain and has increased her mobility substantially, which enabled the complainant to resume her normal day to day activities. 

 

The complainant further submitted that for the above said treatment the complainant has spent a sum of Rs.1,25,000/- and the amount for the therapy was paid to SBF Healthcare & Research Centre.  The complainant after paid the amount obtained the necessary details of the treatment afforded to her has lodged a claim for payment of Rs.1,25,000/-.  Based on the treatment summary given by the SBF Healthcare & Research Centre dated 14.01.2017.  The OPs have repudiated the claim of the complainant dated 09.03.2017 stating that “It is evident from the medical records, there was no continuous 2 hours hospitalization and treatment was taken on day care basis, hence claim is not payable.”

The complainant further submitted that the reason is duly illegal, unwarranted and the legitimate amount expended by the complainant for which, the complainant was eminently eligible for reimbursement.  In this regard, the complainant states that as earlier, for severe joint pains namely Osteoarthritis, the only effective remedy was to undergo knee replacement surgery which was not only time consuming but also expensive covering number of days of hospitalization.  Wg. Cdr. Dr.V.GVasishta (Retd) who has an MD in Radiology has conducted extensive research in the said field.  The research and clinical trials indicated substantial relief to several patients and therefore have been published in several National and International journals of repute.  Wg. Cdr. Dr.V.GVasishta (Retd) has successfully treated hundreds of patients from different walks of life including dignitaries such as Her Excellency Mrs.Pratibha Patil, the Hon’ble former President of India, Mrs.Renuka Chowdhury, former Hon’ble Minister for Women & Child Development, Air Chief Marshall I.H Latif (Retd), former Chief of the Air Staff, Ambassador to France, former Governor of Maharashtra and former Governor of Uttarkhand who have given laudable remarks commending the treatment afforded to them by Wg. Cdr. Dr.V.GVasishta (Retd) who is the Chief Executive Officer of SBF Healthcare and Research Centre.  It is also pertinent to state that, in the wake of success of the medical research of Wg. Cdr. Dr.V.GVasishta (Retd), the State Government of Karnataka has designated him with ‘SUWARNA KARNATAKA RAJYOTSAVA AWARD’ which speaks for itself.

That as per the terms of the policy itself, there is no whisper that treatment for Osteoarthritis is precluded from seeking reimbursement.  The every clause quoted by the OPs, has no application at all to the facts and circumstances of the case.  Further, the treatment is a result of technological advances which results in the growth of new cartilage.  Complainant further submits that, as enumerated above, the said therapy is the brain child of Wg. Cdr. Dr.V.GVasishta (Retd) who is a highly qualified professional and has an MD in Radiology.  The same fact has also survived the test of the Consumer Fora and cannot be considered a ground for repudiation.  The Hon’ble State Commission has also expressly held that the said treatment even if taken is as an inpatient, should be allowed.  Moreover, Osteoarthritis is an age-related disorder, and repudiation of age related disorders after collecting premiums from senior citizens amounts to ‘unfair trade practice’.  The complainant has caused legal notice to the OPs on 23.06.2017 calling upon the OPs forthwith reimburse amount claimed by the complainant.  However, despite sufficient time, there is no reply for the same and therefore complainant is constrained to approach this Forum.

 

3. In response to the notice issued, OPs appeared through their advocate and filed their version contending in brief, as under:

 

OP submitted that the complainant is a guilty of suppression of material facts and misrepresentation and have not come before this Forum with clean hands.  Further the complainant knowing fully well that treatment she has obtained comes under the Exclusions of insurance policy has still come up before the Forum only to harass the OPs.

 

OPs further submitted that the complainant had obtained the ‘Health Benefit Plus Insurance’ policy with OP.  The complainants claims that she had severe pain in her knee joints and which revealed Osteoarthritis and hence was treated with SPMF (Sequentially Programmed Magnetic Field) therapy for 21 days continuously.  The complainant has made a claim with the OPs for payment of Rs.1,25,000/- as per the treatment summary.  However OPs have rejected the claim for the reason that there is no continuous 24 hours hospitalization and treatment and that the treatment taken by the complainant is on day care basis which is not covered under the insurance policy.  That the rejection of claim made by the OPs is wholly as per the terms of the policy which was well aware by the complainant before making the claim.  The relevant policy conditions are reproduced here as under:

 

B. DEFINITIONS & INTERPRETATIONS

 

…

Hospitalisation

 

Hospitalisation means admission in a Hospital for a minimum period of 24 in patient Care consecutive hours except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours.

 

…

In-Patient care

 

In-Patient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

 

OPD Treatment

 

OPD treatment is one in which the Insured visits a clinic/hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner.  The Insured is not admitted as a day care on in-patient.

 

…

 

Exclusions for Hospital Confinement Benefit Plan

 

13. Outpatient treatment.

 

OPs further submitted that, OP is not liable to pay any amount much less than the claim made by the complainant for the reasons that the complainant underwent SPMF, Magnetic field therapy for knee pain and there was no continuous hospitalization for 24 hours.  The treatment that she took was for two to three hours everyday.  That as per the policy, hospitalization for a minimum of 24 hours is required and the policy excludes outpatient treatment.  The complainant knowing very well about the said terms of the policy has filed this complaint only to harass the OPs.  It was clearly informed to the complainant that the claim made is not covered under the policy since the complainant was treated on OPD basis and not hospitalised for a continuous period of 24 hours.  In addition, it is also clearly intimated to the complainant that unproven treatment is not payable.  The relevant exclusion clauses under the policy produced here as under:

 

Exclusions for Hospital Confinement Benefit Plan

 

The Company shall not be liable under this Policy for any claim in connection with or in respect of:

 

…

 

20. Any treatment received in convalescent homes, convalescent hospitals, health hydros, nature cure clinics or similar establishments.

 

23. Any other Alternative Treatments except Allopathy (Modern Medicine).

 

27. Any claim in respect of Unproven/Experimental treatment.

 

OPs further submitted that the complainant being well aware as per the terms and conditions of the policy and after having understood the same and has confirmed the same by affixing her signature to the policy, cannot now come and make a claim before the OPs that too after undergoing a treatment.  The complainant after undergoing the treatment which is unproven and which is without hospitalization for 24 hours.  Hence there is no deficiency of service on the part of OPs.  Further in the report it clearly states that during the treatment of the complainant was effected joints were exposed to radiofrequency beams for one hour followed by physiotherapy for one hour and observation for one hour and that her total stay at the centre was three hours every day and the complainant had obtained the treatment in a clinic and not a hospital and there is no admission facility in the said clinic and the said clinic does not come under the purview or the norms of the insurance.  The treatment obtained is the magnetic therapy which is considered as an alternative therapy and which is not considered for any claim under the insurance policy.  Moreover the complainant has not admitted to the hospital for 24 hours.  There is no deficiency of service on the part of OPs as alleged by the complainant.  Hence OPs prays for dismissal of the complaint in the interest of justice and equity.

 

4. In the course of enquiry into the complaint, the complainant and the OPs have filed their affidavit reproducing what they have stated in their respective complaint and objections.  Complainant has produced certain documents.  Complainant and OP have produced written arguments.  We have heard the arguments of complainant and OPs and we have gone through the oral and documentary evidence of both parties scrupulously and posted the case for order.

 

5. Based on the above materials, the following points arise for our consideration;  

 

1. Whether the complainant has proved that there is deficiency in service on the part of the OP, if so, whether she is entitled for the relief sought for?

 

 

2.  What order?

 

6. Our findings on the above points are as under:

 

Point No.1:  Affirmative in part

Point No.2:  As per the order below

 

REASONS

 

 

 

7.Point No.1:-Admittedly the complainant obtained ‘Health Benefit Plus Insurance’ plan bearing No.SL00032564000107 from OP.  It is also admitted fact that the complainant was suffering from pain in her knee joint and which reveals Osteoarthritis and hence she was treated with SPMF for 21 days continuously for one hour every day followed by physiotherapy for ½ hour at SBF Healthcare & Research Centre and was treated by Wg. Cdr. Dr.V.GVasishta (Retd).

 

8. The complainant submitted that after the above said treatment the complainant submitted claim form along with documents to claim a sum of Rs.1,25,000/- from OP.  The OPs repudiated the claim on the ground that, there was no continuous 24 hours hospitalization and the treatment was taken on day care basis as Ex-A3.

9. On perusal of the Ex-A3 the OP has repudiated the claim of the complainant only on the ground that the complainant had taken a treatment on day care basis and not admitted to the hospital for 24 hours.  On perusal of the terms and conditions of the policy hospitalization column it is written here as under:

 

Hospitalisation

 

Hospitalisation means admission in a Hospital for a minimum period of 24 In patient Care consecutive hours except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours.

 

10. On the above said condition it clearly mentioned that admission in a hospital for a minimum period of 24 hours is continuously is necessary.  Further it is also mentioned that in exceptional treatments where such admission could be for a period of less than 24 consecutive hours is admissible.  In the instant case the complainant advised by Wg. Cdr. Dr.V.GVasishta (Retd.) to take Sequentially Programmed Magnetic Field Therapy (SPMF) continuously for one hour daily for 21 days.  The said doctor who is an MD in Radiology who has conducted the extensive research in the said field and several patients who were taken a treatment under SPMF therapy has got a relief.  Regarding the said therapy has been published in several National and International journals.  Further Wg. Cdr. Dr.V.GVasishta (Retd) has also got a award ‘SUWARNA KARNATAKA RAJYOTSAVA AWARD’ by Government of Karnataka.  The Wg. Cdr. Dr.V.GVasishta (Retd), advice the complainant for SPMF therapy for 21 days daily.  According to the advice of the doctor the complainant took the treatment and got a relief from the pain.  The complainant submitted that due to the treatment she is able to do her day to day work/activities without any knee pain.

 

11. Further the said treatment taken by the complainant is exceptional treatment.  As per the advice of the treating doctor the complainant took a treatment on day care basis with less cost.  On a similar issue Hon’ble National Commission in R.P.No.2362/14 dtd.23.02.2015 in the case of New India Assurance Co., Ltd., &Anr., v. IshuMotwani was pleased to consider a similar matter wherein the Hon’ble National Commission has held that one hour treatment continuously for 21 days would be entitled for reimbursement.  Further the above said judgment para.7 of the order which reads here as under:

 

Brief perusal of the Policy shows that it is a Goodhealth Policy Certificate issued on 1.9.2012 to the insured who is 61 years of age.  Issuing a Policy to a person of 61 years of age and then stating that ‘age related diseases’ are excluded amounts to unfair trade practice.  When SPMF Therapy is not specifically excluded, the act of the Opposite Parties 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.

 

12. In the light of the above said judgment and based on the facts and circumstancesthe complainant is entitled for reimbursement of the claim under day care treatment.  The complainant has spent Rs.1,25,000/- towards treatment.Therefore, we are of the opinion that the complainant is entitled to a total sum of Rs.1,25,000/- only.  Since OPs have repudiated the claim of untenable ground, they are liable to pay interest on the said sum of Rs.1,25,000/- @ 9% p.a from the date of repudiation till the date of realization.Looking to the facts and circumstances of the case, we feel it appropriate to direct the OPs to pay compensation of Rs.10,000/- and litigation cost of Rs.10,000/- to complainant.  Accordingly, we answer the point no.1 in the affirmative.

 

          13. Point No.2: In the result, we passed the following: 

 

 

 

O R D E R

 

1) The complaint filed by the complainant is allowed in part.

 

2) OPs.1 & 2 jointly and severally directed to reimburse the claim amount of Rs.1,25,000/- to the complainant together with interest at the rate of 9% p.a from the date of repudiation till the date of realization.

 

3) Further OPs.1 & 2 jointly and severally directed to pay compensation of Rs.10,000/- with litigation cost of Rs.10,000/- to the complainant.

 

4) This order is to be complied by the OPs.1 & 2 within 30 days from the date of receipt of this order.

 

5) Supply free copy of this order to both the parties.

 

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Forum on this 09^thday of January 2020)

 

 

 

(ROOPA N.R)                                             (PRATHIBHA R.K)

   MEMBER                                                     PRESIDENT

 

 

 

 

 

Witnesses examined on behalf of the complainant by way of affidavit:

 

Smt.Prabha Devi K.P.

 

 

 

Copies of documents produced on behalf of complainant:

 

Ex-A1	Copy of policy terms and conditions.
Ex-A2	Copy of treatment summary and consolidated bill from M/s.SBF Healthcare and Research Centre dated 24.12.2016.
Ex-A3	Copy of letter of repudiation dated 09.03.2017.
Ex-A4	Copy of laudable remarks in respect of Wg. Cdr. Dr.V.GVasishta (Retd) CEO of SBF Healthcare and Research Centre.
Ex-A5	Copy of legal notice dated 23.06.2017 caused to the Respondents.
Ex-A6	Copy of postal endorsement for having received the legal notice.
Documents	Copies of authorities (two in numbers)

 

 

Witnesses examined on behalf of the OP by way of affidavit:

 

Sri.Sandeep K.P, who being working as State Head, Legal and   TP Claims, Royal Sundaram General Insurance Co. Ltd., Bangalore.

 

Copies of documents produced on behalf of Opposite Party:

 

Ex-B1	Copy of claim form along with the policy document.
Ex-B2	Copy of claim note.
Ex-B3	Copy of investigation format of the OP for health insurance claim of the complainant.
Ex-B4	Copy of summary of treatment.
Documents	Copies of authorities (two in numbers)

 

 

 

 

(ROOPA N.R)                                             (PRATHIBHA R.K)

   MEMBER                                                     PRESIDENT

 

 

 

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