IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Saturday the 31st day of December, 2016
Filed on 02.05.2014
Present
1) Smt. Elizabeth George (President)
2) Sri. Antony Xavier (Member)
3) Smt. Jasmine D (Member)
in
CC/No.121/2014
Between
Complainant:- Opposite parties:-
Sri. Akhil. K. Mani 1. Star Health and Allied Insurance
Kulakkattu Veli Co. Ltd., Registered Office &
Avalookkunnu P.O. Corporate Office New Tank Street
Alappuzha – 688 006 Valluvar Kottam High Road
(By Adv. Jayan. C. Das) Nungambakkam, Chennai – 600 034
2. Star Health and Allied Insurance
Co. Ltd., Branch Office, South of
T.D. School, Thirumala Bus Stop
M.O. Ward, Alappuzha
(By Adv. T.S. Suresh – for opposite
parties)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
Complainant had taken a policy from the opposite party for the sum assured for Rs.1,50,000/- on 22.05.2012 vide it’s Policy No. P/181212/01/2013/000176 from the office of the 2nd opposite party. The complainant was suffering from uncontrolled Type II DM and secondary to Morbid Obesity and diabetes for the past several years. He has taken several treatments from various hospitals to have the diabetes cured. But all the treatments taken by him went in vein. Later he was admitted in Moulana Hospital & Scanning Centre, Ooty Road, Perinthalmanna, Malappuram for the resolution of his diabetes. The Chief Surgeon of the hospital had advised the complainant to undergo Mini Gastric Bypass for the resolution of his diabetes. Accordingly the complainant had undergone Laparoscopic Mini Gastric Bypass on 7.2.2013. The above said operation had done with main intention of resolution of diabetes of the complainant. The complainant was admitted in the Moulana Hospital & Scanning Centre on 6.2.2013 and operation was done on 7.2.2013 and he was discharged on 11.2.2013. An amount of Rs.2,40,000/- had spent by the complainant for the above said treatment. The hospital authorities had issued the bill to the complainant for the said amount. Later the complainant had claimed for the policy amount covered under his policy with the opposite parties by furnishing the necessary hospital documents. However, the opposite parties have rejected the claim put forward by the complainant. The opposite parties vide it’s letter dated 7.2.2013 informed the complainant that, the operation which he had undergone will not cover the policy clause of the complainant. Alleging deficiency in service on the part of the opposite parties, the complaint is filed.
2. The version of the opposite parties is as follows:-
The complainant had taken medi-classic individual policy from the opposite party vide policy No. P/181212/2012/00093 from 12.5.2011 to 11.5.2012 which has been renewed up to 22.5.2014 and the sum assured was Rs.1,50,000/-. It is submitted that the complainant was admitted on 6.2.2013 at Moulana Hospital, Malappuram and diagnosed Morbid Obesity uncontrolled T2DM & he underwent Mini Gastric Bypass surgery. The opposite party received a pre-authorization request from the hospital on 6.2.2013 for extending the cashless facility to the patient. In the pre-authorization form, the provisional diagnosis has been recorded as Morbid Obesity, T2DM. It is submitted that as per the Exclusion No.19 in the policy condition “Expenses incurred on weight control services including surgical procedure for the treatment of Obesity medical treatment for weight control/loss programs” are excluded under the policy issued. Since the Obesity treatment is not covered under the policy, the cashless facility was rejected by the opposite party and informed the same to the hospital on 7.2.2013. It is submitted that Mini Gastric Bypass surgery is indicated for the surgical treatment of Morbid Obesity, a diagnosis which is made when the patient is seriously obese. The complainant never preferred any claim with supporting documents to the opposite parties, since there is a violation of condition of the policy. The opposite parties are not liable to indemnifying the insured. There is absolutely no illegal lapse, unfair practice and deficiency in service by the opposite parties.
3. The complainant was examined as PW1. Documents produced were marked as Exts.A1 to 5. Opposite party was examined as RW1. Documents produced were marked as Exts.B1 to B4.
4. The points that arose for consideration are as follows:-
1) Whether there is any deficiency in service on the side of the opposite parties?
2) If so the reliefs and costs?
5. It is an admitted fact that complainant had taken a policy from the opposite party for the period from 12.5.2011 to 11.5.2012 which has been renewed up to 22.5.2014 and the sum assured was Rs.1,50,000/-. According to the complainant, he was suffering from Type II DM and secondary to Morbid Obesity and diabetes for the past several years and he had undergone laparoscopic Mini Gastric Bypass surgery on 7.2.2013 at Moulana Hospital, Malappuram and had spent an amount of Rs. 2, 40,000/- for the above said treatment. When the complainant had claimed for the policy amount covered under his policy, the opposite parties have rejected the claim stating that the operation which he had undergone will not cover the policy clause of the complainant. Opposite party filed version stating that since the Obesity treatment is not covered under the policy, the cashless facility was rejected by there. They further stated that the Mini Gastric Bypass surgery is indicated for the surgical treatment of Morbid Obesity diagnosis which is made when the patient is seriously obese. As per exclusion No.19 in the policy condition, “expenses incurred on weight control services including surgical procedure for the treatment of Obesity medical treatment for weight control/loss programs” are excluded under the policy issued. Opposite party has produced the copy of the policy and it marked as Exxt.B2. According to the complainant, he has undergone the surgery with main intention of resolution of his diabetes. In order to substantiate the allegation, complainant has produced the discharge card which marked as Ext.A2 and treatment certificate issued by the Doctor which marked as Ext.A3. On verifying Ext.A2 discharge card under the title diagnosis it is mentioned that as diagnosis Type II DM Morbid Obesity. In Ext.A3 treatment certificate, it is clearly mentioned that, “Mr. Akhil. K. Mani, 23/M, Kulakkatuveliyil House, Avalookkunnu P.O. Alappuzha Dt. was suffering from uncontrolled Type II DM, and secondary to Morbid Obesity. He has underwent Laparoscopic Mini Gastric Bypass with main intention of resolution of his diabetes which should happen only with weight reduction.”It is manifest from a plain reading of the Ext.A3 document that the insured was a patient of diabetic mellitus and he has underwent the surgery with main intention of resolution of his diabetes. It is pertinent to notice that complainant is aged 23 years and if he was suffering from uncontrolled Type II DM at that stage it should be controlled by using medical devices. It is not a cosmetic surgery. As per Ext.A3 the complainant was underwent Laparoscopic Mini Gastric Bypass with main intention of resolution of his diabetes which should happen only with weight reduction and as such the opposite party has no right to repudiate the claim of the complainant. As per Ext.A4(2) the medical expenses incurred by the complainant is amounts to Rs.2,40,000/-. But as per the policy issued by the opposite party the sum assured is Rs.1,50,000/-. Since the opposite parties had committed deficiency in service on their part, the complainant is entitled to get the insured amount for the treatment that he had undergone. In the result, complaint is allowed. The opposite parties are directed to pay the insured amount of Rs.1,50,000/- (Rupees one lakh and fifty thousand only) to the complainant with 8% interest from the date of complaint till realization. The opposite parties are further directed to pay an amount of Rs.2,000/- (Rupees two thousand only) towards costs of this proceedings to the complainant. Since the primary relief is granted no order as to compensation. The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in open Forum on this the 31st day of December, 2016.
Sd/- Smt. Elizabeth George (President):
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt. Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant”-
PW1 - Akhil. K. Mani (Witness)
Ext.A1 - Copy of the policy schedule
Ext.A2 - Copy of the discharge card
Ext.A3 - Copy of the certificate
Ext.A4 (1) - Copy of the bill of Maulana Hospital
Ext.A4(2) - Copy of the bill of Maulana Hospital
Ext.A5 - Copy of the rejection letter
Evidence of the opposite parties:-
RW1 - Manu Mohan (Witness)
Ext.B1 - True copy of the policy schedule
Ext.B2 - Copy of the policy condition
Ext.B3 - True copy of the pre-authorization
Ext.B4 - True copy of the rejection letter
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S/F
Typed by:- pr/-
Compared by:-
