Order-15.
Date-16/06/2015.
Complainant Mrs. Parama Roy by filing this complaint submitted that she is a bonafide medi-claim policy holder bearing Standard Medi-claim Policy No. 10040048128500008410, sum assured for Rs. 4,00,000/- and domiciliary hospital benefit of Rs. 1,00,000/- valid of the policy period was from 05.03.2013 to 04.03.2014.Complainant continued her medi-claim policy since 2009 and the present policy is the continuation of the previous policy and present policy was issued on 05.03.2013.
Op Insurance Company offered bonus in the last year policy for Rs. 1,00,000/- against treatment and against domiciliary hospital benefit of Rs. 5,001/-.During the policy period complainant was admitted in Belle Vue Clinic, Kolkata on 26.11.2013 under Dr. Surendra Ugale when on 22.11.2013 after examination to the complainant, Dr. Ugale advised for admission at Belle Vue Clinic on 26.11.2013.Accordingly complainant was admitted at Belle Vue Clinic with the complaint of Metabolic Syndrome with post history of Type-2 Diabetes Mellitus with metabolic syndrome plus systemic involvement and cirrhosis of lever and Dr. Ugale operated the patient on 27.11.2013 and treatment was done as Sleeve Gastrectomy with Sympathetectomy plus Liver Biopsy under General Anesthesia” and the complainant was discharged after treatment on 02.12.2013 from the said Clinic and for the purpose of such operation and treatment complainant spent Rs. 3,45,547/- and complainant as per Medi-claim Policy claimed the same before Insurance Company by way of filing claim form on 16.12.2013.
Fact remains that complainant continued the treatment when she first consulted with Dr. Tapas Chakarborty on 25.09.2013 and when Dr. Tapas Chakraborty examined her it was detected that she has been suffering from acute Diabetes and before that there was no knowledge about that past history.
Subsequently Insurance Company vide letter dated 17.02.2014 repudiated the claim of the complainant under Clause 4.19 of Standard Medi-claim Policy.Complainant challenged such illegal repudiation and wrote one letter dated 14.03.2014 to the grievance cell of the insurance company and explained because surgery is a life saving exercise to eradicate diabetes and protect multiple organs of the body and the said surgery is not to give aesthetic focus or cosmetic in nature or the process or removal of fat surgically and the complainant was not a patient of obesity before or after surgery.But suffering from severe joints pain, thyroid, hypertension and abnormal glucose count and after post operation complainant was completely cured of hypertension, thyroid and pains in limbs, joints and others.Complainant along with said letter dated 14.03.2014 submitted medical surgeon’s opinion and observation and requested the insurance company for re-consideration of her legitimate claim.
In reply to such letter of the complainant, ops vide letters on 25.03.2014 and 02.04.2014 that the matter shall be considered though Kolkata Division No. IV office but this Division office reported that after reviewed the claim, it had been repudiated.But it specifically mentioned that obesity cannot be extended to include metabolic syndrome and metabolic syndrome is prevalent commonly in morbid obese patients and is not merely associated with collection of fat in the stomach.It is also associated with production of hormones and also related to functioning of glands and surgery is the only treatment procedure available to get relief from all cited ailments and the cause of morbid obesity is metabolic syndrome which is not at all a cosmetic surgery.But op did not consider the same and illegally repudiated the claim for which complainant submitted the said repudiation is baseless and on fake ground for which complainant has prayed for relief.
On the other hand op nos. 1 & 2 by filing written statement submitted that the insured is a policy holder no doubt and she preferred the claim being No. HH111409720 for her admission on 26.12.2013 in Belle Vue Clinic and she was discharged on 02.12.2013 and after considering the discharge certificate, treatment sheet of Mrs. Parama Roy for the treatment of disease of sleeve gastrectomy for Metabolic Syndrome with systematic involvement cirrhosis of liver and PFT test was done in Belle Vue Clinic on 18.11.2013 and it was found that obesity is found BMI>30.So, the present patient was a patient of obesity and sleeve gastronomy is weight reducing Smgeny and it helps in diabetes indirectly by reducing weight.
Considering the above fact and Clause 4.19 the said claim was repudiated as it was a treatment for obesity and after considering all the materials, the op repudiated the claim and there was no legality and fact remains that the Forum has no scope to bypass the policy under any circumstances and parties are guided by the terms and conditions for which the present claim is not tenable and in fact the complainant suppressed the entire matter and appeared before this Forum to get illegal fund from the present op.So, the complaint should be dismissed.
Decision with reasons
On comparative study of the complaint and written version including the discharge certificate as filed by the complainant and also other documents, it is clear that treatment was done by the Belle Vue Clinic in respect of the patient for sleeve gastrectomy for Metabolic Syndrome with systematic involvement cirrhosis of liver on 27.12.2013 under general anesthesia, so it is a treatment.Now question of sleeve gastrectomy for Metabolic Syndrome with systematic involvement cirrhosis of liver is a surgery for weight losing or for other purpose.
Fact remains that Dr. Ugale and Dr. Tapas Chakraborty are expert in Sleeve Gastrectomy and diagnosed her Metabolic Syndrome with systematic involvement of cirrhosis of liver.But admitted position is that complainant is a patient Type-2 Diabetes Mellitus for long period.Now the question is whether Sleeve Gastrectomy with Metabolic Syndrome and systematic involvement of cirrhosis of liver comes under the purview of treatment of obesity or condition arisen there from including morbid obesity and any other weight control programme/services as per Clause 4.19 terms and conditions of the policy when it is included in Exclusion Clause and if any treatment comes under the purview of 4.19 clause, in that case no insured shall have to get any benefit in respect of the claim for such treatment.
No doubt op repudiated the claim on the ground that the said treatment was for weight loss and as per medical science, sleeve gastrectomy with Metabolic Syndrome are jointly done to reduce the Hypertension and Hormones produced by the stomach which may contribute the weight loss and after considering the different medical experts opinion from foreign journals, it is found that sleeve gastrectomy is only applied in case of obesity and for weight loss and no doubt the sleeve gastrectomy with metabolic syndrome are generally done by the doctor in case of a person who has excessive fat in his/her body system and to remove the fat this surgical procedure is made and by that procedure the size of stomach is reduced and no doubt from the discharge certificate, it is also found and from other test, it is clear that complainant was a patient of obese and excessive fat was there for which to control the fat, said operation was done and it is no doubt relatively new method of treatment to lose fat and by that process the muscle that control entering of food from stomach to intestine sleeve gastrectomy is dealt with it.
No doubt complainant was admitted for loss of his weight that is fat and weight loss is generally faster with the help of the present operation and that has been done.No doubt it is a surgical procedure.So, apparently it is found that the said treatment was for loss of fat and loss of weight and invariably such sort of treatment was given to the patient who is a patient of obesity.
Fact remains that due to obesity a person must have to suffer from diabetes and other co-related problem and when the obesity is out of control, in that case sleeve gastrectomy with metabolic syndrome is must for removing the fat and to control and for controlling the excessive weight.No doubt Dr. Ugale specifically mentioned that it is metabolic syndrome that is systematic involvement and to control and clear diabetes, fat of the organ of the body’s, he was admitted.But all over India Dr. Ugale is known doctor as specialized to control the obesity but when the patient claims any certificate, he issues such sort of certificate and in another case Dr. Ugale submitted such certificate to the patient.
But truth is that medical journals and authors support that it is related to obesity treatment and considering the medical certificate, discharge certificate and also the renowned medical authors opinion in different journal about sleeve gastrectomy with metabolic syndrome and considering their opinion, we are convinced to hold that this present treatment which was done by the Dr. Ugale on the present complainant was a treatment for obesity including morbid obesity and for weight control programme or service.So, apparently as per policy Exclusion Clause 4.19 for such sort of treatment, no insured is entitled to get any benefit even if there is any mediclaim policy and truth is that in case patient of suffering from obesity it is common prescription of doctor DM or HTM and the present operation is necessitated to correct the obesity that is metabolic syndrome.
So, considering all the above fact and circumstances, materials we are convinced to hold that this Forum cannot go beyond the terms and conditions of the policy and fact remains that in the present case it was a treatment for obesity related and complainant was suffering from that and for that problem, complainant is not entitled to get any benefit on the ground it was completely a treatment for weight loss and fat and so as per Clause 4.19, complainant is not entitled to get any disbursement of the policy claim and such sort of claim is not tenable in view of the terms and conditions that is Exclusion Clause 4.19 and it is settled principle of law that complainant’s present claim was rightly repudiated by the op and in this regard we have gathered that there was no deficiency or negligence on the part of the op and truth is that complainant is bound by clause as mentioned in the said terms and conditions of the policy and this Forum cannot go beyond the contract in view of the mandatory provision of law that parties are guided by and are covered by the terms and conditions of the policy and Forum has no scope to bypass it in any circumstances.
So, in the above circumstances we are convinced to hold that the complaint bears no merit and complainant is not entitled to get any benefit of the claim as the treatment as taken by the complainant from the Belle Vue Clinic which is a treatment for weight loss, fat loss and due to obesity and obesity of the patient was also found in the test report.So, the present complaint fails.
Hence, it is
ORDERED
That the complaint be and the same is dismissed on contest without any cost against the ops.
