Order No. 20 dt. 22/08/2017
The case of the complainant in brief is that the complainant in order to meet some health problems consulted a doctor who advised her for laparoscopic sleeve gasterectomy to protect her those problems. The complainant accordingly took admission on 12.08.2013 and she was discharged on 16.08.2013. After her release she applied to o.p. insurance company for medical reimbursement of the bills to the tune of Rs.2,52,700/- It was alleged by the complainant at the relevant point of time the complainant was insured with the insurance company. It was stated by the complainant that the o.p. after submission of the bills by the complainant repudiated a claim of the complainant on the basis of the clause 18 of the exclusion clause of the policy. It was further alleged by the complainant that the repudiation was made arbitrarily and the complainant entitled to get the bill amount from the o.p. insurance company. The complainant by filing this case prayed for direction upon the o.p. company for releasing the said amount as well as compensation and litigation cost.
O.p. insurance company contested the case by filing w/v and denied all the material allegations of the complaint. It was clearly stated that the insurance under this policy is subject to conditions, clause, warranties, exclusions etc. attached. It was further alleged that the rights and liabilities of parties are strictly circumscribed by the contract of insurance and only such contractual rights can be enforced which have been settled down by Hon’ble National Commission. The complainant was admitted in Kirloskar Hospital, Hyderabad. As per the discharge summary:
1. the diagnosis was metabolic syndrome with morbid obesity
2. the insured admitted with the history of pain in knee joint and back sleep apnoea, hypertension, dislipidemia and laparoscopic sleeve, gastrectomy.
As per the opinion of the expert the proximate cause of thesubject treatment was actually due to obesity for which weight reduction procedure was undertaken and accordingly as per the claim of the complainant was not admissible under the terms and conditions of the policy and as per exclusion clause 18 of the policy the claim of the complainant was repudiated and there was no deficiency in service on the part of the o.ps and the complainant will not be entitled to get any relief as prayed for.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with the o.p. insurance company?
- Whether the complainant underwent for an operation?
- Whether the complainant was entitled for the reimbursement of the medical bills ?
- Whether the repudiation of the claim of the complainant was made as per the terms of the policy?
- Whether there was any deficiency in service on the part of the o.p. insurance company?
- 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 in order to meet some health problems consulted a doctor who advised her for laparoscopic sleeve gasterectomy to protect her those problems. The complainant accordingly took admission on 12.08.2013 and she was discharged on 16.08.2013. After her release she applied to o.p. insurance company for medical reimbursement of the bills to the tune of Rs.2,52,700/-.
Ld Lawyer for the complainant emphasized that in spite of having the valid policy and submission of the bills within the one month from the date of release the insurance company illegally repudiated the claim of the complainant for which the complainant filed this case praying for direction upon the o.p. for releasing the amount of the medical bills.
Ld lawyer for the o.p. argued that as per the discharge summary it appears that the complainant admitted to the said hospital for metabolic syndrome with morbid obesity. The morbid obesity is reduced by gastric sleeve resection is done as a weight reduction procedure for persons who are too much above the average weight or who are morbidly obesity. As per Clause 18 of the policy which clearly stated that the exclusions in respect of enjoyment of the medical expenses by the policy holder and the said exclusion clause categorically stated that expenses incurred on weight control services including surgical procedures for treatment of obesity, medical treatment for weight control/loss programmes. On the basis of the said exclusion clause 18 of the policy the claim of the complainant was repudiated. There was no deficiency in service on the part of the o.p. insurance company and accordingly the complainant will not be entitled to get any relief as prayed for.
Considering the submission of the respective parties it is an admitted fact that the complainant was insured with the insurance company at the relevant point of time. It is an admitted fact that during the subsistence of the policy the complainant underwent an operation It is undisputed fact that after releasing from the hospital the complainant submitted bills to the o.ps for reimbursement of the medical expenses incurred by her to the tune of Rs.2,52,700/-. It is found from the materials on record that the claim of the complainant was based on the policy issued to her by the o.ps. On perusal of the discharge summary as well as the certificate produced by the o.p. insurance company wherefrom it is evident that the patient had morbid obesity and she had various problems in order to remove those defects she was admitted to hospital. It is also found from the materials on record that the complainant continued the policy for four years after payment of the premium for so many years and due to her problems and as per advice of her doctor she underwent the said operation. It appears from the materials on record that the insurance company in order to avoid the payment of the medical bills illegally denied the claim of the complainant as per exclusion Clause 18 of the said policy. It is found from the materials on record that the complainant had other medical problems associated with obesity and for removal of those defects she had to undergo the said operation as per the advice of the doctor. Accordingly we hold that the repudiation of the claim of the complainant was made without any cogent ground whatsoever and for avoiding the payment of the medical bills of the complainant the insurance co. relied on the exclusion clause 18 of the policy. Therefore we hold that there was deficiency in service on the part of the insurance company and the complainant will be entitled to get the relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered.
That the case no.25/2014 is allowed on contest with cost against the o.p. insurance company. The o.p. insurance company is directed to pay Rs.2,52,700/- (Rupees two lakhs fifty two thousand seven hundred) 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.10,000/- (Rupees ten thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
