1.5L payout for denying non-surgical method claim

Mumbai: An insurance company and a third-party administrator will have to pay a Mahim resident the insured amount of Rs 1.1 lakh and a compensation of Rs 45,000 for wrongly repudiating his claim.      The man had undergone a non-invasive treatment to treat his cardiac ailment. Oriental Insurance Co Ltd, through Vipul MedCorp TPA Pvt Ltd, rejected Devdatta Redkar's claim on the grounds that it was an unproven treatment. On March 18, 2009, Redkar underwent coronary angiography. He was diagnosed with ischemic heart disease and advised bypass surgery.      However, at another centre he was advised to undergo enhanced external counter pulsation treatment (EECPT), which was non-invasive.      Redkar said he underwent 45 EECPT sittings at a cost of Rs 1 lakh. The treatment lasted from April 2009 to June 2009. In May 2009, he informed theinsurance company about the treatment and its estimated cost after which he filed a claim of Rs 1.10 lakh. On July 27, 2009, the insurance company told Redkar that the investigations done and supportive treatment received were consistent with the disease and line of treatment was in accordance with the diagnosis. However, the procedure fell under the policy's exclusion clause. The insurer stated that the expenses are related to an unproven procedure. Redkar filed a complaint on December 31, 2010. The forum relied on the evidence that the treatment is an accepted treatment for heart disease.