MS. NIPUR CHANDNA (MEMBER)
ORDER
12.03.2024
1. The complainant has filed the present complaint alleging the deficiency in service on the part of OP. The complainant is the holder of mediclaim policy of OP Ins. Co. vide policy bearing no. 360801/48/13/8500002890 w.e.f. 05.10.2013 to 04.10.2014 for a sum insured of Rs. 11 Lakh for himself, his wife and his daughter.
2. It is alleged by the complainant that his wife developed problem in her knee and as such he consulted to Dr. Ashish Jain, of Fortis Hospital, Shalimar Bagh, Delhi who after diagnosis advise TKR (total knee replacement)/ bariatric surgery. It is further stated that complainant also consulted Dr. Praveen Bhatia of Bhatia Global Hospital and Endo Surgery Institute who after conducting the various tests admitted complainant’s wife on 24.03.2014 and operated her for ‘Laproscopic Sleeve Gastrectomy under general Anesthesia ’ and was discharged on 28.03.2014. It is alleged by the complainant that on 25.03.2014, he informed OP-2 regarding the hospitalization of his wife and also lodged the claim with OP-1 for a sum of Rs. 2,91,093/- with OP Ins. Co.
3. The OP-1 Ins. Co. vide its letter dated 05.05.2014 closed the claim of the complainant by stating the reason that the policy does not cover the expenses incurred on treatment of obesity or condition arising there from including morbid obesity and any other weight control treatment vide exclusion clause 4.9. It is further alleged by the complainant that the OP Ins. Co. arbitrarily rejected the claim of the complainant without considering the object of mediclaim policy and the guidelines issued by the Government of India in respect to the exclusion clauses in the policy. It is further stated that the complainant is the policy holder of the OP Ins. company since October, 2005 as such the repudiation is unjustified and illegal. It is further stated that the repudiation of the claim by OP sets a glaring example of deficiency in service on the part of OP, hence, this complaint.
4. Notice of the complaint was sent to OPs. The OP-2 chooses not to contest the complaint. OP-1 filed its written statement wherein it denied any deficiency in service on its part. It is further stated by OP-1 that as per the opinion of the TPA and the documents submitted by the complainant the claim of the complainant is not admissible as per exclusion clause 4.9 of Ins. Policy. It is further stated that Mrs. Raksha Goyal undergo ‘Laproscopic Sleeve Gastrectomy under general Anesthesia ’ and the policy in question does not cover the expenses incurred on treatment of obesity or condition arising there from including morbid obesity and any other weight control treatment vide exclusion clause 4.9, hence, the claim of the complainant is rightly repudiated. It is further prayed that the present complaint be dismissed with cost being frivolous one.
5. Complainant filed his evidence by way of affidavit. He has placed on record the copy of policy documents, copy of prescription dated 10.03.2014 of Fortis Hospital, copy of discharge summary of Bhatia Global Hospital, copy of letter dated 26.03.2014 issue by OP-2, copy of claim form and copy of repudiation letter dated 05.05.2014 in support of his contention.
Mr. Surender Rai Sr. officer filed evidence on behalf of OP. OP failed to place on record any documentary evidence in support of its contention.
6. Both the parties filed their respective written arguments. We have heard complainant counsel Sh. Binod Aggarwal and Sh. D.K. Sinha proxy on behalf of Sh. Vijay Gupta counsel for OP who has been authorized by OP counsel to argue.
7. It is argued on behalf of complainant that he is the mediclaim policy holder of OP Ins. Co. since 2005. It is further argued by Ld. Counsel for complainant that wife of the complainant was operated by the doctors not for the purpose of obesity and weight control programme but for the treatment of Knee Osteoarthritis and Sleep Apnea, hence the claim of the complainant does not fall in the exclusion clause and as such the repudiation is not justified. It is further argued that since the policy in question is the oldest one and continuous renewed with OP the rejection is arbitrary unjustified and illegal. It is further prayed that the prayer clause be allowed and relief claim be granted.
On the contrary it is stated on behalf of OP ins. Co. that since the claim of the complainant fall under exclusion clause 4.9 of the policy terms and conditions the repudiation is justified and present complaint case be dismissed with cost.
8. The sole question for our consideration in the present complaint case is whether the claim in question falls under the exclusion clause as stated by OP and whether the repudiation of the claim by OP under the pretext of exclusion clause 4.9 of the policy terms and condition is justified or not.
9. The OP Ins. Co. in its pleading had averred that the wife of the complainant under gone the treatment of ‘Laproscopic Sleeve Gastrectomy under general Anesthesia ’ and as per clause 4.9 of the policy terms and condition the aforesaid treatment is excluded under exclusion clause of the policy in question. Despite bare averments no documentary evidence has been placed on record by OP1 Insurance Company to justify its contention. OP1 Insurance Co. has neither placed on record the Policy document nor has placed on record the policy terms and conditions under the pretext of which OP Ins. Co. is justifying the repudiation. Due to lack of documentary evidence OP Ins. Co. failed to justify the grounds of repudiation taken by it for denying the claim in question.
10. In view of the above discussion we are of the considered opinion that OP Ins. Co. failed to establish the grounds of repudiation incorporated in the repudiation letter dated 05.05.2014. On the contrary the complainant has placed on record the entire medical treatment record as well as bill justifying the hospitalization claim in question.
11. We therefore allow the present complaint thereby holding OP-1 Ins. Co. guilty of deficiency in service and directing it as under:-
i) pay to the complainant a sum of Rs. 2,91,093/- along with interest @6% from the date of filing of complaint i.e. 11.08.2014 till realization.
- Pay to the complainant a sum of Rs.20,000/- toward compensation for pain and mental agony suffered by him which will include the cost of litigation.
OP is directed to comply the order within 30 days from the date of receipt of this order failing which OP is liable to pay to the complainant interest @9% per annum from the date of non-compliance till realization.
File be consigned to record room.
Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving the application from the parties in the registry.
Order be uploaded on www.confonet.nic.in.
Announced in open Commission on 12.03.2024.
Sanjay Kumar Nipur Chandna Rajesh
President Member Member
