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Sri Bhupendra Sharma along with his family and dependent parents was covered under his employer’s corporate group Health Insurance Policy for a sum insured of Rs.5.00 lakhs. He preferred a claim on the insurer for in-patient prostate cancer treatment of his father. His father underwent High Intensity Focused Ultrasound [HIFU] ablation for prostate cancer. The insurer/TPA denied the claim stating that the treatment was an experimental and unproven treatment / therapy. Aggrieved by the rejection of the insurer, Sri Bhupendra Sharma filed this complaint for redressal.
The complainant stated that his 72 year old father was suffering from Prostate Cancer and it was first detected on 18.4.2009. They preferred to undergo treatment at Rajiv Gandhi Institute and Research Centre at Delhi. He further stated that keeping in view his father’s age and physical condition, they chose HIFU treatment instead of surgery and radiation.
The complainant stated that HIFU treatment was yielding better results than surgery and radiation especially for senior citizens without any complications and so they opted for that treatment. He stated that the rejection of claim by the TPA / Insurer was unjustified and added that the insurer’s reason for “repudiation that “HIFU or radical surgery or chemotherapy or radiotherapy can be construed to be „Experimental / Unproven treatment” since the success of treatment and the prognosis of the disease is unpredictable” was incorrect.
He stated that he submitted to the insurer certificates issued by hospitals of various other countries where it was accepted as a specific treatment for “cancer prostate”.
The insurer stated that HIFU for prostate cancer was still under trial for safety and effectiveness. They further stated that it was not recommended as a specific treatment for ‘cancer prostate’ as per NICE clinical guidelines [33] and American Cancer Society [7]. The insurer contended that this treatment was outside the scope of the policy as per exclusion No. 4.13.
O R D E R
The insurer denied the claim on ground that HIFU ablation is still an experimental or unproven treatment. That HIFU treatment is widely recognized in Europe, Canada and elsewhere in the world is not in dispute. The US FDA is yet to accord recognition to the method. It is common knowledge that there is no proven treatment for complete cure of carcinoma.
There is enough outcry against use of chemotherapy for treatment of cancer. Its success rate as a cure for cancer is still in doubt. Yet, it is widely used for treating carcinoma. If there is one sure method recognised for treating cancer, the insurer would be justified in rejecting claim on HIFU ablation treatment. The policy does not state that the treatment has to be recognized by any specific authority. It only excludes treatment which is undergoing clinical trials.
The reason for such exclusion is that costs associated with such treatments are high and the outcome is uncertain. HIFU ablation treatment is not under clinical trials. It is being employed in Europe and Canada as also in the other parts of the world for treatment of prostate cancer. It is acknowledged to be as effective as or more effective than any other IMA certified treatment for the problem.
In view of the above, it was held that the insurer rejected the claim unreasonably. The expenses towards hospitalisation incurred amounted to Rs.2,74,771 against which the admissible claim works out to Rs.2,39,442 as per the information furnished by the TPA. The insurer is directed to settle the claim at Rs.2,39,442.“In the result, the complaint is allowed in part at Rs.2,39,442.
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