Order No. 9 dt. 12/03/2019
The case of the complainant in brief is that the complainant along with his wife was/is enjoying the medicalim policy of o.p. no.2. The complainant filed this case for non payment of the claim made by the complainant. It has been stated by the complainant that the wife of complainant was admitted to the hospital on 21/09/2017 and she underwent a laparoscopic surgery for hernia on 22/09/2017 and the complainant filed claim for reimbursement of medical charges amounting to Rs.1,75,171/-. The complainant filed all the necessary documents along with his claim. On 17/10/2017 the complainant received an intimation from o.p. no.1 that the claim of the complainant cannot be ascertained from the documents filed by the complainant, but the complainant provided the documents from the treating doctor that the diagram was present on the assessment sheet dt. 15/09/2017 and submitted to o.p.no.1. Subsequently the complainant received a letter on 01/12/2017 that the complainant’s claim has been recommended for repudiation under Clause no. 4.9 of the National Mediclaim. The information was given to the complainant to the effect that the claim has been rejected because the claim arises, in connection with obesity. After receiving such letter the complainant again informed the o.p.no.1 by obtaining the letter from the treating doctor whereby it was stated that the cause of operation cannot be ascertained to obesity and also the patient does not fall under morbid obesity. Since the claim of the complainant was repudiated by o.ps for which the complainant filed this case praying for direction upon the o.ps. for reimbursement of the medical bills of the complainant to the tune of Rs.1,75,171/- as well as compensation and litigation cost.
In spite of receipt of notice the o.p. no.1 did not contest this case by filing w/v and as such, the case has proceeded ex parte against them.
The o.p. no.2 contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that as per the data given in respect of the said patient / complainant’s wife whereby the height of the patient was mentioned 144 cms (1.44 m) and weight was74 Kgs. Therefore, BMI = Weight in Kg / Height in m2 = 74 / (1.44 x 1.44) = 35.7. Obesity is when BMI > 30 so the concerned patient was obese. As per the clause 4.9 under exclusion clause 4 states that treatment of obesity or condition arising there from and any other weight control and management programme / services / supplies or treatment is excluded as per the terms of the condition. On the basis of the said fact o.p. no.2 pprayed for rejection of the claim of the complainant.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the mediclaim policy with the o.ps?
- Whether the claim of the complainant was repudiated as per the exclusion clause?
- 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 along with his wife was/is enjoying the medicalim policy of o.p. no.2. The complainant filed this case for non payment of the claim made by the complainant. It has been stated by the complainant that the wife of complainant was admitted to the hospital on 21/09/2017 and she underwent a laparoscopic surgery for hernia on 22/09/2017 and the complainant filed claim for reimbursement of medical charges amounting to Rs.1,75,171/-. The complainant filed all the necessary documents along with his claim. On 17/10/2017 the complainant received an intimation from o.p. no.1 that the claim of the complainant cannot be ascertained from the documents filed by the complainant, but the complainant provided the documents from the treating doctor that the diagram was present on the assessment sheet dt. 15/09/2017 and submitted to o.p.no.1. Subsequently the complainant received a letter on 01/12/2017 that the complainant’s claim has been recommended for repudiation under Clause no. 4.9 of the National Mediclaim. The information was given to the complainant to the effect that the claim has been rejected because the claim arises, in connection with obesity. After receiving such letter the complainant again informed the o.p.no.1 by obtaining the letter from the treating doctor whereby it was stated that the cause of operation cannot be ascertained to obesity and also the patient does not fall under morbid obesity. Since the claim of the complainant was repudiated by o.ps for which the complainant filed this case praying for direction upon the o.ps. for reimbursement of the medical bills of the complainant to the tune of Rs.1,75,171/- as well as compensation and litigation cost.
Ld. lawyer for the o.p. no.1 argued that as per the data given in respect of the said patient / complainant’s wife whereby the height of the patient was mentioned 144 cms (1.44 m) and weight was74 Kgs. Therefore, BMI = Weight in Kg / Height in m2 = 74 / (1.44 x 1.44) = 35.7. Obesity is when BMI > 30 so the concerned patient was obese. As per the clause 4.9 under exclusion clause 4 states that treatment of obesity or condition arising there from and any other weight control and management programme / services / supplies or treatment is excluded as per the terms of the condition. On the basis of the said fact o.p. no.2 prayed for rejection of the claim of the complainant.
Considering the submissions of the respective parties it is an admitted fact that the wife of the complainant was the beneficiary of the mediclaim policy along with her husband and during the subsistence of the said policy she was admitted to the hospital and as per the advice of the doctor the patient underwent an operation for hernia. After getting release from the hospital the complainant submitted the claim for reimbursement of the medical bills to the tune of Rs.1,75,171/- to o.ps. It is also an admitted fact that the complainant at the time of application for reimbursement of the medical bills submitted all the required documents. It is undisputed fact that the policy was valid at the relevant point of time. The only point for dispute arose between the parties whether the patient was treated for hernia which caused due to obesity. The complainant in order to clarify the said fact obtained the medical documents from the doctor who certified that the cause of ventral hernia cannot be ascertained, but it is due to weakness of the umbellical region. The o.p. no.2 in order to substabntiate the allegation that the claim made by the complainant falls under the exclusion clause no.4.9 of the policy condition filed some documents. On perusal of the documents as well as the medical papers submitted by the complainant it appears that the wife of the complainant underwent a surgery for hernia and not obesity, therefore, the question of body mass index (BMI) is totally irrelevant. BMI is necessary to determine whether, patient is obese or morbidly obese and holds no importance in this situation. It is a trend of o.p. to reject claims on ground of obesity by claiming that the claim of the complainant falls under the exclusion clause 4.9 of the policy conditions. Therefore, we hold that it is unjustified on the part of o.ps. to assume and presume without any justifiable cause that the complainant’s wife developed hernia because her condition of obesity. It is relevant to mention here that the complainant has stated that his wife underwent an operation prior to such treatment of hernia and in support of the said contention the complanant has emphasized that as per the observation of Department of Surgery at the University of California, San Fransisco, USA “a ventral or incisional hernia specifically describes a hernia, often in the middle of the abdomen, that occurs after a prior incision was made during a prior operation. The size of the hernia varies considerably from small to gigantic”. Having regard to the facts and circumtances of the case we hold that o.p. no.2 (insurance company) in order to evade their responsibility for payment of the medical reimbursement bill of the complainant has taken this plea that the patient suffered from hernia due to her obesity which has been categorically denied by the complainant by placing supporting documents of the treating doctor as well as relying on the observation of Department of Surgery at the University of California, San Fransisco, USA. In view of the facts and circumstances as stated above, we hold that there is gross deficiency in service or unfair trade practice on the part of o.p. insurance company and the complainant will be entitled to get the relief. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.248/2018 is allowed on contest with cost against the o.p. no.2 and dismissed ex parte without cost against the o.p. no.1. The o.p. no.2 is directed to pay the claimed amount of Rs.1,75,171/- (Rupees One Lakh Seventy Five Thousand One Hundred and Seventy One) only to the complainant along with compensation of Rs.20,000/- (Rupees Twenty Thousand) only for harassment and mental agony and litigation cost of Rs.5,000/- (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.
