Times of India
08 June 2011
By Rebecca Samervel
Mumbai, India

Coming to the aid of policy holders who are often short–changed by medical insurance companies, a consumer forum recently ruled in favour of an Andheri resident whose claim had been rejected by his insurance provider.

The Mumbai Suburban Consumer Redressal Forum ordered HDFC Ergo General Insurance Company Ltd to reimburse Rs 1.18 lakh at 9% interest to Dharamdas Pritiani, a heart patient who underwent a rare and stateof–the–art treatment. The interest is to be calculated from the date Pritiani filed the claim. The company has also been directed to pay an addition Rs 5,000 to Pritiani for mental agony.

Pritiani bought a medical insurance policy from the company for the period 2008–09. Pritiani experienced difficulty in breathing and underwent a series of tests to ascertain the cause. An angiography revealed that he suffered from a heart ailment, following which he was advised to undergo treatment immediately. Pritiani then underwent a treatment called Enhanced External Counter Pulsation (EECP). The treatment was completed in 45 sittings and required both medicines and special equipment.

Pritiani incurred expenses amounting to Rs 1.18 lakh and claimed this amount from his insurance company. However, the company rejected his claim in May 2009 saying the treatment was experimental and not recognized by it.

Pritiani argued that the treatment was recognized by the US and over 700 hospitals abroad provided EECP. As many as 40 hospitals in India use EECP method to treat heart patients, he claimed. Pritiani then filed a complaint in the forum on November 23, 2009.

Justifying its rejection of Pritiani’s claim, the insurance company said that a policy holder must be hospitalized for at least 24 hours for reimbursement.

Pritiani filed documents in the forum showing that another insurance company had reimbursed a client in a similar case. He also submitted documents describing the exact nature and method used in the treatment. Pritiani also cited a 2007 order passed by the Thane District Consumer Redressal Forum directing an insurance company to pay the reimbursement to another patient who had undergone EECP.

Taking the medicines and the equipment into consideration the forum observed that EECP looked like it was "state–of–the–art treatment". It observed that the company did not provide any evidence to support its claim that the treatment was only being implemented on an experimental basis in India. The forum relied on a clause of the insurance company stating that the 24–hour rule will not apply if a "state–of–the–art treatment" did not require hospitalization.