This appeal is directed against the final order delivered by Ld. D.C.D.R.F. Alipurduar dated 06.09.2019 in Reference to CC No. 5 of 2018. The fact of the case in nutshell is that one S. Das registered the Consumer Complaint who shall be treated as appellant in this case and Bajaj Allianz General Insurance Company Ltd who happens to be the O.P. of the original case shall be treated as respondent in this case. The fact of the case in nutshell is that the appellant S. Das filed a Consumer Complaint to the affect that he purchased the Health Insurance Policy styled as “Star Package” from the respondent Insurance Company on 11.05.2016 and thereafter again on 11.05.2017 he purchased another policy from the said company. Both the policies were covered the amount of Rs. 20 Lakh as sum assured. Thereafter during the policy period the appellant started to suffering in illness like Hyper tension, Hyper Thyroid, Dyslipidenia, Obstructive Sleep, Abnoca (OSA) and Dibetic Retinopathy and he was shifted to Apollo Hospital at Chennai where he got admitted on 02.10.2017 where he had to undergone a metabolic surgery as a life saving procedure and was discharged on 04.10.2017. He informed about this treatment to the Insurance Company in due process and submitted the claim for reimbursement in accordance with the terms and conditions of the policy. But the Insurance Policy has repudiated the claim and for that reason this Consumer Complaint was registered before the Ld. Forum.

Ld. Forum has admitted the Consumer Complaint on its own merit and sent notice to the address of the respondent company who has appeared before the Ld. Forum and contested the case by filing the written version and denied of the material allegations levelled against them and contended inter-alia that the medical costs which has been claimed for reimbursement was related only to weight management services and that process of treatment was not included in the terms and condition of the package policy and for that reason there was no legitimate claim on the part of the insured/appellant. Both parties of this case have filed evidences swearing by affidavit and counter-affidavit and filed the W.N.A. Ld. Forum after hearing both sides and after consulting all the material documents placed before them has come to a conclusion that the appellant had concealed certain facts and he had not come in clean hand and the terms and condition of the Insurance Policy also justified the repudiation of claim on the part of the Insurance Company. So, the Consumer Complaint was dismissed on contest. Being aggrieved with the said order this appeal follows on the ground that the observation of the Ld. Forum was bad in law and not in accordance with any merit and liable to be set aside. The appeal was duly admitted on merit and the respondent was asked to contest the appeal by sending the notice to them who has contested the appeal through Ld. Advocate Mr. J.P. Pawa. The appeal was registered on 11.11.2019 and it was admitted on 19.11.2019. The respondents recorded their presence on 20.12.2019 and since then they have been contesting the case through Ld. Advocate Mr. Pawa. We know very well that the countrywide lockdown due to attack of Corona Virus onset since March 2020 and thereafter the appellant stopped to appear before the Commission to pursue his appeal. Lastly, the case was fixed for hearing the argument on 26.02.2021. Again, on that day the appellant did not take any steps. The Ld. Advocate of the respondent has conducted the hearing on the part of the respondent. Written Note of Argument also submitted on the part of the respondent.

Decision with reasons

Admittedly, the appellant S. Das has purchased the policy on 11.05.2017 and the said health policy covers the period between 11.05.2017 and 11.05.2020. The list of medical papers show the insured S. Das got admitted in the department of Bariatric Surgery under Dr. R. Krishna at Apollo Hospital, Chennai and he had gone in a surgery thereon 02.10.2017 and discharged from the hospital on 04.10.2017. For such surgery he had the liability to pay Rs. 3,72,403. Now, the question is whether he is entitled to get the reimbursement of the cost incurred by him from his Insurance package. Ld. Advocate of the respondent at the time of argument highlighted the general inclusion Clause No. 22 where it was categorically stipulated in the Insurance coverage that any kind of weight management services and treatment related to weight reduction programs including treatment of Obesity are completely excluded from the policy package. In reference to his argument, he referred the judicial decisions of Hon’ble Higher forums as follows…

1. 2018(4) CPR 562 (NC)
2. 2018(1) CPR 319 (NC)
3. 2017(2) CPR 414 (NC)
4. 2017(3) CPR 520 (NC)

 After going through all the observations of the Hon’ble National Commission in the cited judgement and on pursuing the arguments of the Insurance Company and the terms and condition of the instant insurance package and after going through the final verdict of the Ld. Forum, the Commission finds ithat the Ld. Forum has rightly observed that the appellant/complainant was not entitled to get any benefit from the insurance package which he purchased and the Insurance Company/respondent had no liability to pay the cost of Bariatric surgery of the appellant/complainant. The order of Ld. Forum found very sound and based on within the provisions of legal juncture and this order does not invite any interference in appeal. Thus, the appeal devoids of any merit.

Hence, it’s ordered

That the instant appeal be and the same is hereby dismissed on contest without any cost.

Let the order be supplied to the parties free of cost. If, they want.