MUMBAI: Not informing about exclusion clause to the policyholder at the time of their seeking of treatment and then denying mediclaim is the fault/negligence of the insurance company- Holding this valid, a consumer court told an Insurance company to pay a compensation of Rs 6 lakh to a patient.
The forum also quashed the insurance company’s reasoning that naturopathy treatment, acupressure, acupuncture, magnetic therapies, experimental and unproven treatment therapies, including drug experimental therapy which is not based on established medical practices in India, are not payable.
The consumer forum categorically observed that an insurance company not raising an objection to an insurer’s intimation about an impending treatment and issuing an inward number implies its consent for the same. It said that on receiving the information, the insurance company should have informed them about the exclusion clause. It stated that the company’s initial permission and later refusal amounted to inconsistent behaviour.
The case relates to residents of Sobo, Salim and Dilshad Maladwala(Complainant). The couple is a subscriber of Mediclaim policy issued by United India Insurance Company Limited since last 18 years and have been paying a heavy premium to the insurance company regularly.
The matter originated after the complainant was feeling pain in his both knees joints and lower back. Following the magnitude of pain, he took medicine from his family doctor and got temporary relief.
The complainant later learnt about the non-evasive treatment of Osteoarthritis called Sequential Programmed Magnetic Field in short ‘SPMF’ being offered by SBF Health care and Research Center Pvt. Ltd, a branch of Bangalore based company. He took an appointment for consultation of Dr Atul Gajare and collected information regarding said treatment. On 29 December, he availed the treatment under the guidance of Dr Gajare. The treatment cost him Rs 2,65,000 for SBF and Rs 6,180.76 for his medicines, amounting to Rs 2,71,180.76 all together.
Prior to taking the said treatment the complainant through e-mail letter gave intimation to the insurance company. The couple told the insurance company that on December 28, 2013, they were told treatment would commence the following day.
A treatment of SPMF was earlier called as RFQMR (Rotational Field Quantum Magnetic Resonance) and does not require hospitalization and is done OPD basis for 21 days continuously.
After the treatment, the complainant claimed their policy. However, the company repudiated the claim stating that clause 4.15 states that,
“Naturopathytreatment, acupressure,acupuncture, magnetic therapies, 4 (CC/117/2015) experimental and unproven treatment therapies including drug experimental therapy which is not based on established medical practice in India is not payable”.
In June 2016, two complaints were submitted before the South Mumbai District Consumer Disputes Redressal Forum regarding the denial.
The Maladwalas told the forum that the refusal was baseless, illegal and extremely discriminatory. “As SPMF treatment is proven the technology and standard treatment accepted worldwide. It has proven to be effective and provides huge relief to patients, eliminating the need for knee replacement surgery, and it does not necessitate hospitalization,” they claimed.
The consumer forum pronounced two orders and did not accept the insurance company’s reasoning that naturopathy treatment, acupressure, acupuncture, magnetic therapies, experimental and unproven treatment therapies, including drug experimental therapy which is not based on established medical practices in India, are not payable.
“The insurance company failed to prove that how treatment was taken by the complainant was unproven. It is pertinent to note that after taking the treatment the complainant healed from her pain of knees,” the forum said in Dilshad’s case.
The forum ruled in favour of the complainants. “The opposite parties (insurance company and Health India TPA Services Pvt Ltd) have committed negligence in repudiation of the complainants’ claim, in addition, kept deficiency in service and unfair trade practice towards the complainant,” the forum said.
The company will now have to pay a compensation of around Rs 1 lakh along with the treatment cost of Rs 4.8 lakh.