West Bengal

Paschim Midnapore

CC/127/2017

Purusottam Agarwal - Complainant(s)

Versus

Divisional Manager, United India Insurance Co.Ltd. - Opp.Party(s)

Asim Kumar Dutta

25 Apr 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

   Bibekananda Pramanik, President,

Pulak Kumar Singha, Member

and

Sagarika Sarkar, Member. 

 

Complaint Case No.127/2017

 

               Sri Purusottam Agarwal, S/o Sagarmal Agarwal, vill. Hamirpur, P.O. Balichak,                                                        

              P.S. Debra, District - Paschim Medinipur.   

                                                                                                                    ………..……Complainant.

                                                                              Vs.

1. Divisional Manager, United India Insurance Co. Ltd. having its Divisional Office at Battalachak, Library Road, Town & P.O. Medinipur, P.S. Kotwali, District- Paschim Medinipur,
2. Heritage Health TPA Pvt. Ltd., NICCO house, 5^TH Floor, 2, Hare Street, P.S. Hare Street, Kolkata -700001,
3. Dr. Surendravgale,
4. Dr. Tapas Chakraborty, both of Belle Vue Clinic, 9, Dr. U.N. Brahmachari Street, Kolkata-700017.

                                                                                                 .....……….….Opp. Parties.

                                                    

              For the Complainant: Mr.  Asim Kumar Dutta, Advocate.

              For the O.P.               : Mr. Sudip Kumar Chakraborty, Advocate.

                                                         

                                                         Date of filing:04/08/2017

Decided on: - 25 /04/2018

                                

ORDER

                          Bibekananda Pramanik, President –This consumer complaint u/s 12 of the C.P. Act has been filed by the complainant Sri Purusottam Agarwal against the above named O.Ps, alleging deficiency in service on their part.

                                                                                                                                                Contd………………..P/                                                          

                                                                                                    ( 2 )

              Complainant’s case, in brief, is as follows:-

               The complainant purchased a health insurance policy from the O.P. no.1 vide policy no.03500028111106943203 covering the period from 22.08.2011 to 21.08.2012 and the said policy was renewed from time to time.  By that policy, the complainant and his wife Smt. Lakshmi Devi Agarwal were under policy coverage and from the year 2014, Naina Agarwal, the daughter of the complainant, was also brought under such insurance coverage which was renewed upto 30.08.2017.  Both the wife and daughter of the complainant started gaining unnecessary fat in their body which restricted their normal life and regular activities for which they were examined Dr. Surendra Ugale and Dr. Tapas Chakraborty of Belle Vue Clinic and they opined that the wife and daughter of the complainant were suffering from Morbid obesity with syndrome and systematic involvement.  As per advice of doctors, both the patients were admitted at Belle Vue Clinic on 6.09.2016 for Beriatric procedure in those Laproscopic Sleev Gastreetomy and they were discharged on 11.09.2016 feom the said clinic.  A sum of Rs.3,37,127/- and a sum of Rs.2,43,550/- respectively were spent for treatment of the wife and daughter of the complainant.  Before such treatment, the complainant intimated the O.P.-Insurance Company on 31.08.2016 and after their discharge, the complainant submitted all bills and vouchers including all medical papers before the O.P.-Insurance Company for reimbursement of medical expenses. Thereafter the O.P.-Insurance Company vide their letter dated 24.10.2016 repudiated the claim of insurance on the ground that the Morbid Obesity with co-morbidities and systematic organic involvement falls under exclusion clause no.4.9 of the policy.  It is stated by the complainant that his wife and daughter were required to be treated by Bariatric surgery to avoid obesity related complications and they were suffering from metabolic syndrome with systematic involvement and as such Bariatric surgery were necessary to save the life of wife and daughter of the complainant and such surgical treatment was not cosmetic surgery or for cosmetic reason.  It is stated that considering the seriousness over the matter, the Lok Sabha Secretariat vide order no. March 2013 adopted the guidelines of Ministry of Health & Welfare Department in respect of allowing bariatric surgery in the service rules of the employees and as such repudiation of claim by O.P. nos.1 & 2 is arbitrary and illegal.  Hence the complainant, praying for an order directing upon the O.Ps to effect payment of Rs.5,80,667/- towards medical expenses of the wife & daughter of the complainant and for other reliefs.

                  O.P. nos. 3&4 appeared in this case and by filling a petition they declared that they will not contest this case.  O.P. no.2 received notice of this case but did not

                                                                                                                                                    Contd………………..P/3

                                                           

                                                                                                    ( 3 )

 appear to contest and as such the case was ordered to be heard ex-parte against O.P. no.2.  O.P. no.1 has contested this case by filing a written objection.  

                   Denying and disputing the case of the complainant, it is the specific case of the O.P.-Insurance Company that the O.P. issued the health insurance policy in question subject to the terms, conditions, exclusions and definitions contained therein and in the event of any claim becoming admissible under the scheme of the policy, the company will pay through TPA.  It is stated that in exclusion clause i.e. clause no.4 of the policy it is categorically mentioned that the company shall not be liable to make any payment in respect of any expenses whatsoever so incurred by the insurer in connection with different heads of exclusion as mentioned in the policy including Convalescence, general debility, run down condition or rest cure, obesity treatment and it’s complications including Morbid obesity etc. as specified in the exclusion clause 4.9 of the policy.  The O.P.-Insurance Company therefore claims dismissal of the complaint.

             To prove his case, the complainant Sri Purusottam Agarwal has examined himself as PW-1 and during his evidence, few documents were marked as exhibits 1 to 13 respectively.  On the other hand, O.P-Insurance Company has examined one Partha Dey, the Asstt. Manager of the O.P Company as OPW-1 and during his evidence, two documents were marked as Exbts. A & B respectively.

                                                        Points for decision

1. Is the case maintainable in it’s present form and prayer?
2. Is there any deficiency in service on the part of the opposite party?
3. Is the complainant entitled to get the reliefs, as sought for?  

                                                Decision with reasons

           Point no.1:-

Maintainability of this case has not been questioned by any of the parties at the time of final hearing of this case.  On perusal of the pleadings of the parties we do not find anything to hold that the case is not maintainable.                                        

           Point no.2:-

It is not denied nor disputed that the complainant obtained a health-insurance policy from the O.P. no.1 and the said policy was renewed from time to time and the policy in question being no.0350002816 PLO 7219300 was renewed covering the period upto 30.08.2017.  It is undisputed that by that policy, Smt. Lakshmi Devi Agarwal & Naina Agarwal were also included under the coverage of the policy in question along with the complainant.  Therefore the fact remains admitted that the complainant as well as his wife and daughter are the consumer under the O.P. According to the complainant, his wife and

                                                                                                                                                Contd………………..P/4

                                                          

                                                                                              ( 4 )

 daughter namely Lakshmi Devi Agarwal and Naina Agarwal both were admitted in Belle Vue Nursing Home, Kolkata on 6.9.2016 as they were suffering from Morbid Obesity with Metabolic syndrome with systemic involvement and they had underwent Bariatric procedure in a Laparoscopic Gastronomy and they were discharged from the said clinic on 11.09.2016. For their such treatment, the complainant incurred a total sum of Rs.580677/-.  Complainant therefore submitted claim of insurance before the O.P.-Insurance Company along with all documents including bills and vouchers but the O.P.-Insurance company repudiated such claim of the complainant on the ground that the said treatment of the Morbid Obesity with associated co-morbidities falls under exclusion clause no.4.9 of the policy.

      It is the settled law that parties to the contract of insurance are bound by the terms and conditions of the policy.  The present claim of insurance is the direct result of the expenses incurred for the treatment and operation of Morbid Obesity with associated co-morbidities and systematic organic involvement.  From the policy in question, we find that as per clause 4.9,  the O.P.-Company is not liable to make any payment under the policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of obesity treatment and it’s complications including Morbid Obesity etc. Here in the present case, it is evident from the evidence of the complainant as well as the medical papers of Belle Vue Clinic that the wife and daughter of the complainant were admitted there and diagnosis was done for Morbid obesity with associated co- morbidities and systematic organic involvement.  Said disease or complication and treatment falls under the exclusion clause no.4.9 of the policy and therefore the O.P.-Insurance Co. did no illegality in repudiating the claim of insurance of the complainant.  In his petition of complaint as well as at the time of hearing argument, a copy of order no March 461/2013 of the Lok Sabha Secretariat was referred and it was submitted that in view of the said order, the complainant is entitled to get reimbursement of medical treatment of his wife and daughter done in Belle Vue Clinic under the policy in question.  We are gone through the said order and found that the said order is applicable only to the employees of the Lok Sabha Secretariat.  So the said order of the Lok Sabha Secretariat is of no help to the case of the complainant.

   In the above facts and circumstances of the case and the discussions made above,  it is held that the O.P.-Insurance Company committed no deficiency in service in repudiating the claim of insurance of the complainant.

  This point is accordingly decided against the complainant.                                                    

            Point no. 3:  

                           In view of our above finding under point no.2, the complainant is not entitled to get  any reliefs, as prayed for. 

                                                                                                                                                     Contd………………..P/                                                          

                                                        

                                                                                                  ( 5 )

 

                          All the points are accordingly disposed of.

                          In the result, the complaint case fails,

                                                 Hence, it is,

                                                        Ordered,

                              that the complaint case no.127 /2017  is hereby dismissed on contest against O.P. no.1 and dismissed against the rest O.Ps without contest, but in the circumstances without cost.

                               Let plain copy of this order be given to the parties free of cost.

 

                Dictated and Corrected by me

                       Sd/-B. Pramanik.              Sd/-P.K. Singha           Sd/- S. Sarkar            Sd/-B. Pramanik. 

                             President                            Member                     Member                      President

                                                                                                                                          District Forum

                                                                                                                                      Paschim Medinipur