KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION

VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL No.695/2017

JUDGEMENT DATED: 30.10.2024

(Against the Order in C.C.No.232/2015 of CDRC, Malappuram)

PRESENT:

APPELLANT:

(by Adv. R. Jagadish Kumar)

Vs.

RESPONDENTS:

JUDGEMENT

HON’BLE JUSTICE SRI. B. SUDHEENDRA KUMAR  :  PRESIDENT

          The appellant is the 2^nd opposite party in C.C.No.232/2015 on the files of the District Consumer Disputes Redressal Commission, Malappuram (for short ‘the District Commission’). The 1^st respondent is the complainant and the 2^nd respondent is the 1^st opposite party therein.

          2.       The 1^st respondent/complainant filed a complaint against the appellant and the 2^nd respondent alleging deficiency in service.  The 1^st respondent/complainant was an employee of Kottakkal Arya Vaidyasala.  He was a member of the health insurance policy group for the period from 13.07.2014 to 29.07.2015. 

          3.       The 2^nd respondent is the Senior Manager of Operations, Employers Benefit, AM-EX Insurance Brokers India Pvt. Ltd and the authorized agent of the 2^nd opposite party/appellant.  The 1^st respondent consulted a doctor in Moulana Hospital and Scanning Centre and admitted there for the treatment of Type II DM (Diabetes Mellitus) and underwent surgery (Sleeve Gastrectomy) on 24.02.2015 as per the advice of the doctor, for the control of Diabetes and comorbidities, under a package.  The total package rate for the above surgery was Rs.2,00,000/-(Rupees Two Lakhs only).  The 1^st respondent was discharged from the hospital on 28.02.2015 and he paid an amount of Rs.2,00,358/-(Rupees Two Lakhs Three Hundred and Fifty Eight only) for his treatment.  Thereafter, the 1^st respondent submitted a claim to the appellant through the 2^nd respondent.  But the same was rejected on the reason that the treatment taken for obesity was not payable as per the policy conditions.  The denial of the claim amounts to clear deficiency in service on the part of the 1^st and the 2^nd opposite parties, contended by the complainant/1^st respondent.

          4.       The 1^st opposite party/the 2^nd respondent filed version contending that the 2^nd respondent was not an employee of the appellant.  The 2^nd respondent was only a broker arranged by the employer of the 1^st respondent, namely, Kottakkal Arya Vaidyasala, for the purpose of negotiating with the appellant/ the 2^nd opposite party.  The duty of the 1^st opposite party/2^nd respondent was to collect the claim form of the insured and submit it before the appellant.  The 1^st opposite party/2^nd respondent is an independent entity and intermediary insurance broker and hence the 2^nd respondent had no role in declining the claim by the appellant.

          5.       The appellant filed version admitting the policy.  However, the appellant contended that since the 1^st respondent had undergone treatment for comorbidities relating to obesity, the 1^st respondent was not entitled to get any amount for the treatment, as there was an exclusion under clause 4.8 of the policy conditions in this regard.  The medical records would show that the 1^st respondent had been suffering from morbid obesity for the last 10 years.  The 1^st respondent had been also suffering from Type II Diabetes for the last six months.

          6.       The 1^st respondent and the appellant had filed proof affidavit.  Exhibits A1 to A9 were marked for the 1^st respondent/complainant.  Exhibits B1 to B3 were marked for the opposite parties.  After evaluating the evidence, the District Commission found that there was deficiency in service and accordingly, the District Commission directed both the opposite parties to pay a sum of Rs.2,00,358/-(Rupees Two Lakhs Three Hundred and Fifty Eight only) towards the expenses for the treatment in the hospital, Rs.1,00,000/-(Rupees One Lakh only) as compensation for mental agony and Rs.10,000/-(Rupees Ten Thousand only) as costs of the proceedings, against which this appeal has been filed.

           7.     Heard. Perused the records.

          8.It is not disputed that the 1^strespondent was treated in Moulana Hospital and Scanning Centre from 24.02.2015 to 28.02.2015 as an inpatient.  He had undergone Sleeve Gastrotomy in the hospital.  It is also not disputed that the insurance policy was valid during the period of his hospitalisation and treatment.  The 1^st respondent submitted a claim immediately after the discharge from the hospital.  However, the said claim was rejected by the appellant on the ground that the treatment taken for obesity was not payable as per clause 4.8 in the policy conditions.

          9.       Exhibit A2 would show that the 1^st respondent had been suffering from Type II DM (Diabetes Mellitus) for six months.  It further appears from Exhibit A2 medical certificate issued from the Moulana Hospital that the 1^st respondent had undergone surgery (Sleeve Gastrectomy) on 24.02.2015.  Exhibit A3 is another medical certificate wherein it is stated that the 1st respondent had undergone laparoscopic sleeve gastrectomy for the control of diabetes and other co-morbidities.  Exhibit A4 would show that he was having fasting blood sugar of only 121 on 23.02.2015.  As per Exhibit A7, the claim submitted by the 1^st respondent was recommended for repudiation in view of clause 4.8 of the conditions of the policy.  Exhibit A9 is the health insurance policy produced by the 1^st respondent, which would show that obesity treatment and its complications including morbid obesity are excluded from the policy. 

          10.     Even though the 1^st respondent did not produce the medical certificates showing the history of the disease, the appellant had collected and produced it.  Exhibit B1 is the claim denial letter wherein the claim of the 1^st respondent was denied on the reason that on scrutiny of the claim papers submitted by the 1^st respondent and the other relevant documents collected by the appellant, the appellant found that the treatment was for obesity and its complications including morbid obesity, which was not payable as per the policy conditions.  Exhibit B2 is the history and physical examination report of the 1^st respondent, which would show that the 1^st respondent had morbid obesity for 10 years and Type II DM for six months.  The Exhibits A2 and A3 would show that the appellant was treated for obesity and complications in connection with obesity.  As per Exhibit B2, the Physician who treated the 1^st respondent did not recommend for any operation.  The recommendation in Exhibit B2 was to control diet and do exercise.  It is clearly stated in page 2 of Exhibit B2 that the appellant had morbid obesity.  The final diagnosis as per Exhibit B2 was also morbid obesity.  Exhibit B2 is dated 23.02.2015.  Exhibit B2 was also issued from Moulana Hospital in connection with the treatment of the 1^st respondent.

          11.     It is clear from ExhibitB2 that the doctor who treated the respondent in the same hospital on 23.02.2015 did not recommend for any surgery, as had been conducted in this case, for type II DM(Diabetes Mellitus) and morbid obesity. As per Exhibit B2, the doctor only advised the 1^st respondent to control diet and do exercise.  Since the condition under clause 4.8 of Exhibit A9 policy stipulates clear exclusion from the cover of the policy for the treatment of obesity related surgery, the 1^st respondent is not entitled to get any amount towards the treatment expense from the appellant. 

          12.     This being the situation, we are of the view that no deficiency in service can be attributed against the appellant.  Consequently, the order passed by the District Commission cannot be sustained.

          In the result, this appeal stands allowed, setting aside the order dated 29.04.2017 passed by the District Commission as against the appellant in C.C.No.232/2015 and the complaint as regards the appellant stands dismissed.  In the circumstance of the case, there is no order as to costs.

The statutory deposit made by the appellant shall be refunded to the appellant, on proper acknowledgment. 

SL