Order by:

Sh.Amrinder Singh Sidhu, President

1.       The complainant  has filed the instant complaint under section 35 of the Consumer Protection Act, 2019  on the allegations that the complainant purchased Family Health Optima Insurance Plan policy bearing No. P/211222/01/2020/000281 for herself as well as for her family members i.e. Rajinder Singh, husband,  Paramjit Kaur (self) and Sukhpreet Singh, son for a sum assured of Rs.6,75,000/- against paid up premium of Rs.20,077/- valid for the period w.e.f. 5.5.2020 to 04.05.2021 and previously, the complainant also purchased the said policy  on 5.5.2018  valid for the period 05.05.2018 to 04.05.2019 and the present policy is the  continuous policy as previously, the complainant also purchased policy  bearing No. P/211222/ 2019/000172 valid for the  period 05.05.2019 to 04.05.2020. Further alleges that during the policy period,  complainant Paramjit Kaur   complained about hypertension on body and pain in joint on 04.03.2021 and she was brought to Fortis Hospital, Mohali where the doctor told that all the diseases were come due to obesity and it is called morbid obesity and advised her to operate the mini gastric bypass. Thereafter, on 15.03.2021 the complainant went to OJAS Super Speciality Hospital, Panchkula where Dr.Amit Garg Bariatric and Metabolic surgeon operated  upon the complainant for lap mini gastric bypass and the complainant was discharged on 18.03.2021 and the treating hospital charged Rs.3,25,000/- + Rs.3764/- for her treatment.  After discharge,  the complainant lodged the claim with the Opposite Parties for the reimbursement of her claim and also completed all the formalities, but the Opposite Parties repudiated the claim of the complainant  allegedly on the ground of violation of terms and conditions i.e. exclusion clause 15  of the policy and the complainant was not aware regarding such conditions of the policy and those conditions are not applicable to the case of the complainant.  Hence, the said act of the Opposite Parties amounts to deficiency. Vide instant complaint, the complainant has sought the following reliefs.

a)       The Opposite Parties may be directed to reimburse the medical claim of the complainant amounting to Rs,3,28,764/-  and also to pay  Rs.50,000/- on account of compensation due to mental tension and harassment caused by the complainant.

b)      The cost of complaint amounting to Rs.11000/- may please be allowed.

c)       And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.       

2.       Opposite Parties No.1 and 2 appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that the complaint of the complainant is liable to be dismissed. It is submitted that admittedly, the complainant and her husband Rajinder Singh and Sukhpreet Singh dependant child   were insured under the policy in question for a sum of Rs.5 lakhs, but  as per the  Exclusion Clause No.15, the Opposite Parties-Insurance Company is not liable to make the payment under the policy in respect of the expenses incurred at the hospital for surgical and treatment of any obesity and weight control.  On scrutiny of claim documents the medical team of the Opposite Parties observed from the indoor case records of the treating hospital that the insured patient has undergone laparoscopic gastric bypass for morbid obesity and based on these findings, the claim was repudiated vide letter dated 18.09.2021 as according to the Exclusion Clause No.15 of the policy, the claim for the medical expenses incurred on the obesity and weight control is not payable.  On merits, the Opposite Parties took up almost the same and similar pleas as taken up by them in the preliminary objections.  Hence, it is prayed that the   complaint may be dismissed with costs. 

3.       In order to  prove  his  case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents  Ex.C2 to Ex.C16 and  closed the evidence on behalf of the complainant.

4.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties No.1 and 2 also tendered into evidence the affidavit of Sh.Sumit Kumar Sharma Ex.Op1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/15 and closed the evidence.

5.       We have heard the ld.counsel for the parties and also  gone through the documents placed  on record.

6.       During the course of arguments, ld.counsel for the Complainant as well as ld.counsel for Opposite Parties   have mainly reiterated the facts as narrated in the complaint as well as in the written statements respectively. We have perused the rival contentions of  the parties and also gone through the record on file.

7.       It is not denial of the Opposite Parties-Insurance Company that the complainant has purchased the policy in question and it is the continuous policy because the complainant has been purchasing the policy since the year 2018 without any break, the copies of the policies of three years were placed and exhibited by the Opposite Parties themselves as Ex.OP1,2/3 on record and it is also not disputed that the complainant alongwith her husband and dependant child were also insured in these policies.  The main grouse of the Opposite Parties for repudiating the claim of the complainant is that as per the  Exclusion Clause No.15, the Opposite Parties-Insurance Company is not liable to make the payment under the policy in respect of the expenses incurred at the hospital for surgical and treatment of any obesity and weight control.  In this regard, the complainant herself placed on record the copy of letter dated 18.09.2021 Ex.C11 issued by the Opposite Parties to her in which it is clearly  mentioned that “It is observed from the submitted discharge summary of the above  hospital that the insured has undergone laparoscopic gastric bypass for morbid obesity. As per policy issued to you IRDAI/ HLT/SHAIP/P-H/V.III/129/2017-184. Exclusion No.15 of the above policy, the company is not liable to make any payment under the policy in respect of  expense incurred at hospital for surgical and treatment of any obesity, weight control.”  It is not disputed that the complainant has take treatment at the hospital for surgical and treatment of any obesity and weight control.  As per Exclusion Clause No.15 of the policy placed on record Ex.OP1,2/2, it is clearly mentioned that Expenses incurred on weight control services including surgical procedures such as Bariatric Surgery and/ or medical treatment of obesity. On the other hand, the complainant has nowhere denied for taking treatment at the hospital for surgical and treatment of any obesity and weight control, neither the complainant ever denied the terms and conditions of the policy in question. As such, we hold that the complainant is not entitled to get the reimbursement under the policy in question from the Opposite Parties for taking the treatment at the hospital for surgical and treatment of any obesity and weight control.     

8.       In view of the aforesaid facts and circumstances of the case,  the complaint of the complainant stands dismissed. Keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Commission.