Order no. 10
The case of the complainant in brief is that the complainant is a mediclaim policy holder being policy no.3112202/48/2017/225 which is a health insurance policy issued by o.p. no.1. The complainant submitted a medical bill of Rs.3,85,808/- with o.ps. on account of the treatment of his wife Sarbani Sinha. It was further stated that the complainant’s wife was admitted to ILS Hospital at Salt Lake on 9.2.17 due to acute lower respiratory track infection and other ailments. The doctor of the said hospital conducted a surgery upon the patient and she was discharged on 1.3.17. The complainant after the recovery of his wife submitted all the medical bills along other documents to o.ps. claiming the amount of Rs.3,85,808/- towards the medical reimbursement, but o.ps. failed to provide the same and repudiated the said claim for which the complainant filed this case praying for direction upon the o.ps. for providing the claim amount of the complainant as well as compensation and litigation cost.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant opted for Happy Family Floater 2015 with sum insured of Rs.6 lakhs since 2012. The patient was diagnosed as morbid obesity with constructive sleep apnoea with type 2 respiratory failure with acute lower respiratory track infection with type 2 DM with hypo thyroidism with OA. The case of the patient is a morbid obesity. During hospitalization the patient was admitted there with the complaint of slow gradually increasing body weight and she underwent surgery laparoscopic mini gastric bypass which is a short simple procedure with low risk and good weight loss and accordingly the claim of the complainant was repudiated as per policy clause 4.20 for contribution clause. It was further stated that PFT test was done in the hospital since it was a case of morbid obesity. The o.ps. shall not be liable oto make any payment under the policy in respect of any expenses whatsoever incurred in connection with the treatment of obesity or condition arisen therefrom including [morbid obesity] and any other weight control programme / services supplies. The said treatment was rendered to the patient was for loss of fat and loss of weight and as per the clause 4.20 the claim of the complainant was not entertained. On the basis of the said fact it was categorically stated by o.ps. that the claim of the complainant was repudiated as per the terms of the policy and there was no deficiency in service or unfair trade practice on the part of o.ps. and as such, o.ps. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided :-
- Whether the complainant had the policy with o.ps.?
- Whether the complainant submitted the medical bills to o.ps for reimbursement?
- Whether repudiation of the claim of the complainant was justifiable one?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons :-
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. Lawyer for the complainant argued that the complainant is a mediclaim policy holder being policy no.3112202/48/2017/225 which is a health insurance policy issued by o.p. no.1. The complainant submitted a medical bill of Rs.3,85,808/- with o.ps. on account of the treatment of his wife Sarbani Sinha. It was further stated that the complainant’s wife was admitted to ILS Hospital at Salt Lake on 9.2.17 due to acute lower respiratory track infection and other ailments. The doctor of the said hospital conducted a surgery upon the patient and she was discharged on 1.3.17. The complainant after the recovery of his wife submitted all the medical bills along other documents to o.ps. claiming the amount of Rs.3,85,808/- towards the medical reimbursement, but o.ps. failed to provide the same and repudiated the said claim for which the complainant filed this case praying for direction upon the o.ps. for providing the claim amount of the complainant as well as compensation and litigation cost.
Ld. lawyer for the o.ps. argued that the complainant opted for Happy Family Floater 2015 with sum insured of Rs.6 lakhs since 2012. The patient was diagnosed as morbid obesity with constructive sleep apnoea with type 2 respiratory failure with acute lower respiratory track infection with type 2 DM with hypo thyroidism with OA. The case of the patient is a morbid obesity. During hospitalization the patient was admitted there with the complaint of slow gradually increasing body weight and she underwent surgery laparoscopic mini gastric bypass which is a short simple procedure with low risk and good weight loss and accordingly the claim of the complainant was repudiated as per policy clause 4.20 for contribution clause. It was further stated that PFT test was done in the hospital since it was a case of morbid obesity. The o.ps. shall not be liable oto make any payment under the policy in respect of any expenses whatsoever incurred in connection with the treatment of obesity or condition arisen therefrom including [morbid obesity] and any other weight control programme / services supplies. The said treatment was rendered to the patient was for loss of fat and loss of weight and as per the clause 4.20 the claim of the complainant was not entertained. On the basis of the said fact it was categorically stated by o.ps. that the claim of the complainant was repudiated as per the terms of the policy and there was no deficiency in service or unfair trade practice on the part of o.ps. and as such, o.ps. prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant is a holder of mediclaim policy since the year 2012. It is found from the materials on record that during the subsistence of the said policy the complainant’s wife became ill and she was treated at ILS Hospital and as per the advice of the doctors of the said hospital the patient i.e. the complainant’s wife underwent treatment. After the recovery from the said treatment the complainant submitted a bill to o.ps. but the same was repudiated on the ground that since the complainant was treated for undergoing metabolic surgery to treat and prevent complications from obesity. Ld. lawyer for o.ps. stated that as per clause 4.20 of the policy the complainant will not be entitled to get the reimbursement of the medical bills since for the treatment of obesity the patient underwent such surgery and accordingly as per the said clause the claim was repudiated by o.ps. On perusal of the materials on record we find that the patient was treated at ILS Hospital by Dr. Om Tatia who issued a certificate stating inter alia that the patient was suffering from morbid obesity along with obstructive sleep apnoea and osteoarthritis. The obesity along with morbidities were greatly hampering day to day activities for which the patient was admitted at the hospital on 9.2.17. The patient was advised to undergo metabolic surgery to treat and prevent complications of obesity. It appears from the materials on record that the patient underwent surgery on 25.2.17. The doctor in the medical certificate categorically stated that metabolic surgery is not a cosmetic surgery and is performed to treat / prevent complications of obesity and related comorbidities. On perusal of the said certificate vis-à-vis the materials on record we find that the treatment underwent by the patient does not fall within the category of clause 4.20 of the policy. On the basis of the facts and circumstances of the case we hold that the complainant incurred the expenses for the treatment of his wife and the policy was valid at the relevant point of time. It appears from the materials on record that the complainant after following all the procedures claimed the reimbursement of the medical bills, but the same was repudiated on the basis of the clause 4.20 of the policy, thereby we hold that o.ps. committed deficiency in service and illegally repudiated the claim of the complainant and as such, the complainant will be entitled to get the relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
that the CC No.381/2017 is allowed on contest with cost against the o.ps. The o.ps. are jointly and/or severally directed to pay the claim amount of Rs.3,85,808/- (Rupees three lakhs eighty five thousand eight hundred eight) only to the complainant along with compensation of Rs.30,000/- (Rupees thirty thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 8% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
