1. This is a complaint filed by Smt.S.Meenakshi - Insurance ...

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such stock as well. It was estimate the value of stock destroyed in the second barn at Rs.30,000and direct the insurer to pay this amount.In fine, the claim of the complainant insofar as the loss/damage to the structure isrestored for fresh examination and assessment of the claims in accordance with the terms ofthe policy. The claim in respect to loss of stocks in the barns is allowed at Rs.65,285 (Rs.35,285plus Rs. 30,000).In the result, the complaint is treated as allowed in part.HYDERABAD OMBUDSMAN CENTRECOMPLAINT No. I.O.(HYD) G -11.04.144.2010-11Sri Bhupendra Sharma V/s United India Insurance Co. Ltd.Award No:G-108/14.09.2010Sri Bhupendra Sharma along with his family and dependent parents was covered under hisemployer’s corporate group Health Insurance Policy for a sum insured of Rs.5.00 lakhs. He preferreda claim on the insurer for in-patient prostate cancer treatment of his father. His father underwentHigh Intensity Focused Ultra Sound [HIFU] ablation for prostate cancer. The insurer/TPA denied theclaim stating that the treatment was an experimental and unproven treatment / therapy. Aggrievedby the rejection of insurer, Sri Bhupendra Sharma filed this complaint for redressal.The complainant stated that his 72 year old father was suffering from Prostate Cancer andit was first detected on 18.4.2009. They preferred to undergo treatment at Rajiv Gandhi Instituteand Research Centre at Delhi. He further stated that keeping in view his father‟s age and physicalcondition, they chose HIFU treatment instead of surgery and radiation. The complainant statedthat HIFU treatment was yielding better results than surgery and radiation especially for seniorcitizens without any complications and so they opted for that treatment. He stated that therejection of claim by the TPA / Insurer was unjustified and added that the insurer‟s reason for
epudiation that “HIFU or radical surgery or chemotherapy or radiotherapy can be construed tobe „Experimental / Unproven treatment‟ since the success of treatment and the prognosis of thedisease is unpredictable” was incorrect. He stated that he submitted to the insurer certificatesissued by hospitals of various other countries where it was accepted as a specific treatment for„cancer prostate‟.The insurer stated that HIFU for cancer prostate was still under trial for safety andeffectiveness. They further stated that it was not recommended as specific treatment for „cancerprostate‟ as per NICE clinical guidelines [33] and American Cancer Society [7]. The insurercontended that this treatment was outside the scope of the policy as per exclusion No. 4.13.O R D E RThe insurer denied the claim on ground that HIFU ablation is still an experimental orunproven treatment. That HIFU treatment is widely recognized in Europe, Canada andelsewhere in the world is not in dispute. US FDA is yet o accord recognition to the method. It iscommon knowledge that there is no proven treatment for complete cure of carcinoma. There isenough outcry against use of chemotherapy for treatment of cancer. Its success rate as a curefor cancer is still in doubt. Yet, it is widely used for treating carcinoma. If there is one suremethod recognised for treating cancer, the insurer would be justified in rejecting claim on HIFUablation treatment. The policy does not state that the treatment has to be recognized by anyspecific authority. It only excludes treatment which is undergoing clinical trials. The reason forsuch exclusion is that costs associated with such treatments are high and the outcome isuncertain. HIFU ablation treatment is not under clinical trials. It is being employed in Europeand Canada as also in the other parts of the world for treatment of prostrate cancer. It isacknowledged to be as effective as or more effective than any other IMA certified treatment forthe problem.In view of the above, it was held that the insurer rejected the claim unreasonably. Theexpenses towards hospitalisation incurred amounted to Rs.2,74,771 against which theadmissible claim works out to Rs.2,39,442 as per the information furnished by the TPA. Theinsurer is directed to settle the claim at Rs.2,39,442.
Page 1 and 2: DELHICase No. GI/223/NIA/09In the m
Page 3: The insurer explained that the poli

1. This is a complaint filed by Smt.S.Meenakshi - Insurance ...

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