Delhi

East Delhi

CC/112/2018

MEENU ARORA - Complainant(s)

Versus

U.I.I. - Opp.Party(s)

02 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 112/2018

 

	Meenu Arora W/o SH. Harvesh Juneja, R/o:- 164, First Floor, Tagore Park, Near Modal Town, DELHI-110009.	….Complainant
Versus
1.       2.           3.	United India Insurance Company Ltd. P 19-20, Ph-I Mayur Vihar, Pandav Nagar, Patparganj, Delhi-110091.   Health Insurance TPA of India Ltd. 2nd Floor, Majestic Omnia Building, A-110, Sector-4 Noida, U.P.-201301. (Removed from the array of parties vide order dated 21.01.2020)   Fortis Hospital A, Block, Shalimar Bagh, New Delhi-110008. (Deleted by order dated 06.06.2018  at the time of admission)	……OP1         ……OP2             ……OP3

 

 

Date of Institution: 05.04.2018

Judgment Reserved on: 25.04.2023

Judgment Passed on: 02.05.2023

               

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

 

Judgment By: Sh. S.S. Malhotra (President)

 

JUDGMENT

 

1. By this Judgment Commission shall dispose off the complaint of the complainant w.r.t. deficiency in not reimbursing the medical expenses borne-out by the complainant.
2. Brief facts stated by the complainant in the complaint are that the complainant had the family Medi-claim Policy No. 2215042817P103731756 from 2003/2005 from the OP and the same was also valid from 16.06.2017-15.06.2018 having total cover of Rs. 8,00,000/- and she paid the premium of Rs. 30,400/-.  The complainant was suffering from poorly controlled Diabetes mellitus Type II, Morbid Obesity with Co-Morbid conditions viz. Diabetic Retinopathy, Hypertension, Hypothyroidism, Dyslipidemia. Joint Pains, Backache, Snoring, Depression & Breathlessness. The complainant in order to treat the aforesaid ailments was advised to undergo "Laproscopic Sleeve Gastrectomy with Duodeno Jejunal Bypass".

 

3. Complainant, accordingly under-went requisite surgery on 27.07.2017and spent amount of Rs. 5,07,074/- and after being discharged on 31.07.2017 she requested the OP for processing the claim for reimbursement but the same was denied under Clause 4.9 of the Insurance Policy on the basis that the obesity treatment and its complication including morbid obesity are not included in the policy & as such cannot be granted under Clause 4.9 of the policy. It is further stated that OP1 has rejected the claim illegally and as such a legal notice was issued upon OP1 & OP2 through her advocate but nothing was paid & consequently she has filed the present case thereby demanding bill amount of Rs. 5,07,074/- & compensation of Rs. 1,00,000/- and litigation charges of 50,000/-.
4. The OP has filed written statement interalia stating in the preliminary objection that the complaint of the complainant is not maintainable as the treatment taken by the complainant comes in exclusion clause. It is further stated that the insured/patient underwent laparoscopic Sleeve Gastrectomy with duodeno-jejunal bypass for Morbid obesity. As per policy exclusion clause no.4.9 (Obesity treatment and its complications including Morbid obesity are not covered. Hence, claim is not admissible and repudiated. Hence, the claim is not maintainable. The clause reads as under:
   • The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:

“Convalescence, general debility, run down condition or rest cure, obesity treatment, congenital external disease or defects or anomalies, sterility, veneral diseases, intentional self injury and use of intoxication drugs/ alcohol”.

 

5. On merit all these facts are reiterated and the claim of the complainant be dismissed.
6. The complainant has filed rejoinder, thereby denying the contents of the written statement reiterated the contention of the complainant. Both the parties have filed their evidence.
7. The Commission has heard the argument and perused the record. The fact that complainant was suffering from poorly controlled Diabetes mellitus Type II, Morbid Obesity with Co-Morbid conditions viz. Diabetic Retinopathy, Hypertension, Hypothyroidism, Dyslipidemia. Joint Pains, Backache, Snoring, Depression, Breathlessness is not disputed. The complainant got admitted in hospital and spent of amount Rs. 5,07,074/-  is also not disputed. The only contention of the OP is that the claim is not maintainable as in terms of the insurance policy clause 4.9, wherein it has been specifically stated that obesity treatment and its complication included morbid obesity are not covered. Clause 4.9 has been mentioned in above in Para 4 of this judgment.

 

8. The Ld. Counsel for the complainant on the other hand has relied upon the judgment of Hon’ble NCDRC in Revision Petition No. 4558 of 2014 in which it was interalia discussed & held:

 (6)   It is submitted that the observations of the opposite party No. 1 & 2 are totally arbitrary, illegal, unreasonable and contrary to social welfare nature of the Medical Insurance policy in as much as the . was not performed for obesity alone but was for curing other ailments viz. Diabetic Retinopathy, Diabetic Neuropathy etc as also detailed in the certificate issued by Fortis Hospital whereby the approval was made for surgery by Dr. Atul N.C Peters detailing the fact that the surgery was not a Cosmetic surgery or for curing obesity but for curing incidental life threatening diseases. That despite having spent huge amount towards premium for almost 12 years, complainant had to encounter the rejection of claim on the same grounds vide dated 16 October, 2017.

9. The Hon’ble NCDRC has made a fine distinction as to what is cosmetic surgery and when it is required as well as what the treatment against the particular disease and interalia held that if it is a disease & has been advised by the doctor’s concerned, then it would not fall within the category of ‘cosmetic surgery’ rather it would be a treatment of disease and ultimately the Hon’ble NCDRC rejected the appeal of the insurance company in the above mentioned case.
10. The fact of the case in hand are to be seen as to whether the patient/complainant went for the surgery on the specific advice of the doctor or it was a cosmetic surgery.
11. The Commission has perused the record. In the entire complaint there is no document which could have suggested that the complainant requires admission in the hospital so as to cure her poorly controlled Diabetes mellitus Type II, Morbid Obesity with     Co-Morbid conditions viz. Diabetic Retinopathy, Hypertension, Hypothyroidism, Dyslipidemia. Joint Pains, Backache, Snoring, Depression, Breathlessness and such other disease, rather the fact is that there is no previous clinical diagnosis filed on record by the complainant which may show that complainant is suffering from certain ailments & for treating those ailment as mentioned in Para 1 of the complaint she need a surgical treatment. Medical History of complainant is filed on record, which does not lead to the conclusion that she required the Laproscopic Sleeve Gastrectomy with Duodeno Jejunal Bypass Laproscopic Sleeve Gastrectomy with Duodeno Jejunal Bypass for the purpose of removing her disease. There is no advice of any doctor placed on record who have advised her to go for such surgical treatment rather facts show that she went of her own to the hospital on 27.07.2017 where her various tests were conducted without referring any previous prescription. There is no document by which doctor is advising her that to cure such disease she requires admission or biotic surgery, she got herself admitted in the hospital and went for the surgery. All the diagnoses test are running from 27.07.2017 to 29.07.2017 i.e. the date on she was discharged. The Commission enquired from the Ld. Counsel for the complainant that there is no prescription on record which may suggest that Laproscopic Sleeve Gastrectomy with Duodeno Jejunal Bypass is advised to the complainant for treating her alleged diseases but Ld. Counsel could not show any advice of the doctor that she requires surgery. However ‘essential certificate’ has been shown from the record. However, why the ‘essential certificate’ was required, has not been explained even otherwise the said essential certificate is dated 03.08.2017 i.e. after the Laproscopic Sleeve Gastrectomy with Duodeno Jejunal Bypass took place. Certian history of the complainant is written but even in that letter/certificate it is not written that this medical treatment was must for the complainant. The certificate obtained from the doctor in the title ‘Essential Certificate’ in the considered opinion of the Commission would not be able to prove that doctor has advised this treatment of Laproscopic Sleeve Gastrectomy with Duodeno Jejunal Bypass to the complainant. The judgment relied upon by the Ld. Counsel for complainant deals with cosmetic surgery as mentioned in the terms & conditions of the policy which that particular case had, but in the present case, the word ‘cosmetic surgery’ is not mentioned at all & what is mentioned the ‘Obesity treatment’.
12. Therefore the judgment as relied upon by the complainant that the complainant had under-went Laproscopic Sleeve Gastrectomy with Duodeno Jejunal Bypass on the advise/opinion of the doctor is not supported with any document and once the opinion/prescription/medicines/treatment advice of the doctor is not on record, it cannot be stated that complainant had under-went this Laproscopic Sleeve Gastrectomy with Duodeno Jejunal Bypass on the advice of the doctor and was essential to cure her serious diseases she was suffering. Therefore the contention of the OP is well found that the treatment of the Morbid Obesity/Cosmetic Surgery for removing of extra weight falls within the exclusion clause 4.9 as reproduced herein above. Therefore complainant is not able to establish deficiency in service on the part of OP and therefore the complaint filed by the complainant is dismissed.  

Copy of the order be supplied/sent to both the parties free of cost as per Rules. 

File be consigned to Record Room.

Announced on 02.05.2023.