Insurance co to pay non-surgical knee therapy claimant

A consumer court has directed the Apollo Munich Health Insurance Company to pay Rs 1 lakh as reimbursement for the money spent on joint pain treatment, including damages and litigation expenses.

The court directed the insurance company after it denied reimbursing the medical claim saying the treatment for osteoarthritis was based on non-surgical magnetic therapy and did not require any hospitalisation.

The insurance company said the new method and technology adopted to cure knee pain without surgery can be termed ‘physiotherapy exercise’.

The complainant, Seethakanthan S V, (70), a resident of JP Nagar had the medical insurance policy -- Easy Healthy Group Insurance -- from the Apollo Munich Health Insurance company.

The complainant developed pain in his right knee joint and opted to undergo sequentially programmed magnetic field (SPMF) therapy at the SPF Healthcare and Research Centre.

The SPMF treatment along with physiotherapy was for half an hour daily for 21 days. Post-treatment, the complainant felt better and applied for his insurance claim of Rs 70,002, based on the treatment summary.

Osteoarthritis

However, the insurance company rejected the claim stating osteoarthritis is precluded from seeking reimbursement. Moreover, the company said the treatment was done on an outpatient basis without any hospitalisation and OPD
treatment was excluded from the scope of coverage in the policy.

The insurance company contended in the court that the treatment undergone by the complainant is part of the rehabilitation measure which is not covered as per policy terms and the hospital was not among the listed empanelled hospitals.

‘Against natural justice’

The First Additional District Consumer Disputes Redressal Forum headed by H R Srinivas and member D Suresh passed an order on March 6 which said the complainant’s treatment is purely a result of technological advance, which results in the growth of new cartilage. Hence, the repudiation of the claim is beyond the scope of natural justice and illegal, which amount to deficiency of service and unfair trade practice on the part of the insurance company.

The court directed the insurance company to reimburse Rs 70,002 along with 12% interest, Rs 20,000, towards damages and Rs 10,000 towards litigation expenses.

The court also directed to pay the amount within 30 days from the date of the order.