Order-18.
Date-05/08/2016.
This is an application u/s.12 of the C.P. Act, 1986.
Case of the complainant, in short, is that in March, 2012 the complainant obtained a health insurance policy known as Optima Restore Policy from the OPs Insurance Companies bearing no.150100/11120/6000023803-01 effective from 27-03-2012 to 26-03-2013 for basic sum of Rs.3 lakhs and multiplier benefit of Rs.1,50,000/-. The complainant also renewed the aforesaid policy in the following year from 27-03-2013 to 26-03-2015 on payment of renewal premium amounting to Rs.9,931-84. On 26-02-2015 suddenly, the complainant suffered shortness of breath with feeling of heaviness in chest. She was taking to Dr. Balaram Prasad and the doctor referred her to Dr. S. Ugale/ Dr. Tapas Chakraborty for valuable opinion. The complainant was taken to Dr. Ugale, attending doctor in the Belle Vue Clinic and after thorough check up and investigations Dr. Ugale advised the complainant to undergo Bariatric surgery to avoid future life risk. Accordingly, on 25-03-2015 the complainant had been admitted with OP3 hospital under Dr. Ugale and Dr. Tapas Chakraborty. On 26-03-2015 Lap Sleevi Gastrectomy was done. On 29-03-2015 the complainant was discharged by the OP3 Hospital. The complainant incurred a total sum of Rs.2,92,415/-. Subsequently, the complainant advanced claim to the OP1 for reimbursement of Rs.2,92,415/-. In the 2nd week of May, 2015 to utter dismay the complainant received a computer generated letter dated 13-05-2015 from OP1 informing that the claim is not payable on the ground that Morbid Obesity is excluded from the policy. Hence this case.
OPs 1 and 2 have contested the case in filing written version contending, inter alia, that the complaint is not maintainable. It is stated that the clause 8 under heading “General Exclusions” as stated in the proposal form envisages that treatment of Obesity and Weight Control Programme is excluded from the scope and purview of the policy. It is also stated that the complainant agreed, acknowledged and accepted the terms and conditions provided in the said insurance policy. On 09-04-2015 OP1 received a claim from the complainant for an amount of Rs.2,92,415/- for reimbursement of expenses incurred on account of hospitalization at the Belle Vue Clinic at Kolkata from 25-03-2015 to 29-03-2015. It is alleged that she underwent “Bariatric Surgery” under the supervision of Dr. S. Ugale for treatment of ‘Morbid Obesity’. It is a surgery for weight loss procedure performed on people who have obesity and it comes u/s.4 Exclusion of the policy. This OP has prayed for dismissal of the case.
Proforma OP3 has also filed the written version stating that the instant complaint is not maintainable against Belle Vue Clinic. It is also alleged that there is no insured element as regards the Belle Vue Clinic is concerned. It is also stated that Belle Vue Clinic has no role in the matter and has been unnecessarily dragged into the proceeding without any specific allegation and absence of any relief claimed against it. It is stated that the case is not maintainable against this answering OP.
Point for Decision
- Whether OPs 1 and 2 have rightly repudiated the claim of the complainant?
- Whether the complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have browsed over the documents on record including the prescriptions of the doctors, Optima Restores Policy, repudiation letter and other medical papers, discharge summary of Belle Vue Clinic, Medical Bills etc. etc. We find that the complainant obtained a Optima Restore Health Insurance Policy from the OP Insurance Company in March, 2012 for Rs.3 lakhs and multiplier benefits of Rs.1.5 lakhs. The said policy was renewed in the following years and lastly in the year 2014 effective till 26-03-2015. On 24-02-2015 the complainant had severe respiratory trouble with feeling of heaviness in chest. She was initially treated by her house physician Dr. Balaram Prasad and ultimately she was taken to Belle Vue Clinic. Dr. Ugale advised the complainant to undergo Bariatric Surgery to avoid future life risk as it is appearing from the prescription. She was admitted there on 25-03-2015. On 26-03-2015 Lap Sleevi Gastrectomy was done. From the discharge summary it appears Lap Sleevi Gastrectomy was done under general anesthesia on 26-03-2015. From the prescription of Dr. S. Ugale dated 27-02-2015 it appears that Sleeve Gastrectomy was advised to avoid future life risk and the operation is not for cosmetic purpose. So, we find that the operation or the treatment thereof was not for weight control programme or treatment of obesity. Ld. Lawyer for the complainant during hearing referred to one order passed by Insurance Ombudsman, Hyderabad on 15-03-2010 wherein it is stated that Sleeve Gastrectomy is a surgical procedure in which a part of the stomach is excised in order to save the patient from morbid obesity and not for cosmetic reasons. In the instant case, we find that the complainant underwent a Gastrectomy surgery. Moreover, Hon’ble National Commission in R.P. No. 3258 of 2013 dated 04-03-2014 has been pleased to observe that the insured is not bound by the Exclusion Clause of the Policy if the same is not explained to him. In the present case, insurance OPs Company have failed to file any evidence to prove, that such clause has been explained to the complainant before commencement of the insurance policy. On the contrary, it appears that prior to admission to OP3 hospital the complainant on 23-03-2015 through e-mail intimated OPs1 and 2 about the admission and treatment while the OPs did not think it necessary to reply thereof. We also find that the policy was initiated in the year 2012 and has covered 36 months meanwhile.
In view of the above and on relying upon the observation of Insurance Ombudsman Hyderabad on 15-03-2010 in AQARD NO.I.O. (Hyderabad) G-131/2009-10 and the judgment passed by the Hon’ble National Commission as stated herein before we think that complainant has proved his case. We hold that the OPs have not been justified in repudiating the claim and have also caused deficiency of service. The complainant is entitled to get the relief as prayed for.
In result, the case succeeds.
Hence,
Ordered
That the instant case be and the same is allowed on contest against the OPs.
OPs 1 and 2 are jointly and severally directed to pay Rs.2,92,415/- to the complainant apart from litigation cost of Rs.10,000/- within 30 days from the date of passing this order.
OPs 1 and 2 are further directed to pay compensation of Rs.20,000/- for harassment and mental agony to the complainant within the said stipulated period, i.d., an interest at the rate of9 percent p.a. shall accrue over the entire sum due to the complainant till full realization.
Failure to comply with the order will entitle the complainant to put the decree into execution u/s.25 read with Section 27 of the C.P. Act.
