Southwest Delhi District Commission Holds United India Insurance Co. Liable For Repudiation Of Genuine Medical Claim

The District Consumer Disputes Redressal Commission-VII, Southwest Delhi bench of Suresh Kumar Gupta(President), Harshali Kaur (Member) and Ramesh Chand Yadav(Member) held United India Insurance Co. Ltd. liable for deficiency in services for repudiating a genuine claim based on the exclusion clause for obesity and its complications. The bench held that the insured was suffering from morbid obesity and the surgery was required as a life-saving measure and not for cosmetic concerns. Therefore, the insurance company wrongfully repudiated the claim. Brief Facts: The deceased Complainant obtained a Mediclaim policy for his family, including himself, from United India Insurance Co. Ltd. (“Insurance Company”), which was continued until 2018-19. According to the Complainant, there was no pre-existing disease or illness regarding any insured person. However, he began suffering from super morbid obesity (weighing 140.4 kg, BMI 54.2 kg/m²), hypertension, sleep apnea, dilated cardiomyopathy, and diabetes mellitus. He was advised to undergo laparoscopic metabolic surgery and underwent laparoscopic sleeve gastrectomy at Sir Ganga Ram Hospital (“Hospital”) to lose weight and combat metabolic syndrome, which he argued was a lifesaving and life-protecting intervention. He was discharged from the Hospital. However, the Third-Party Administrator (“TPA”), via a letter denied him a cashless facility under exclusion clause 4.9, forcing him to pay Rs. 4,25,097/- to the Hospital. After submitting the bills to the TPA, his claim was repudiated under clause 4.9 of the policy by the Insurance Company, which excluded coverage for the treatment of obesity and its complications. Feeling aggrieved, the Complainant filed a consumer complaint in the District Consumer Disputes Redressal Commission-VII, Southwest Delhi (“District Commission”) against the Insurance Company. The Insurance Company contended that health insurance is a contractual agreement subject to the policy's terms and conditions. It argued that obesity and its complications, including morbid obesity, were explicitly excluded under clause 4.9 of the policy. Therefore, it argued that the claim was rightly repudiated based on the policy's terms, leaving the complainant without any cause of action to file the complaint. Observations by the District Commission: The District Commission referred to the exclusion clause and the medical evidence provided, including a certificate from the doctor, which indicated that morbid obesity and its associated conditions represented a life-threatening situation, necessitating laparoscopic metabolic surgery as a life-protecting intervention. The District Commission rejected the Insurance Company's argument that the surgery was for obesity, as the surgery was necessitated by the life-threatening nature of morbid obesity. Referring to the United India Insurance Co. Ltd. vs Sunil Gupta and Anr. [(2015) 2 CPR NC 635], the District Commission noted that morbid obesity is recognized as a serious disease with severe, life-threatening complications and that laparoscopic metabolic surgery is considered a lifesaving procedure rather than a cosmetic one. The District Commission noted that the doctor's certificate, which supported the necessity of the surgery for non-cosmetic, life-saving purposes, was not challenged by the Insurance Company. Thus, it held that the surgery was not performed for cosmetic reasons or to improve physical appearance but was a necessary intervention to address a serious medical condition. Additionally, the District Commission found that the exclusion clause in the insurance policy was not adequately communicated to the Complainant. Therefore, the District Commission held that the Insurance Company wrongfully repudiated the complainant's claim, constituting a deficiency in service. Consequently, the Insurance Company was ordered to pay Rs. 4,25,097 to the legal representatives of the Complainant. Additionally, it was directed to pay Rs. 50,000/- as compensation for mental harassment and agony, and Rs. 30,000/- for litigation expenses. Case Title: Navneet Arora and Ors vs United India Insurance Company Ltd. Case Number: CC/19/234 Date of Pronouncement: June 5th, 2024Click Here To Read/Download Order

Southwest Delhi District Commission Holds United India Insurance Co. Liable For Repudiation Of Genuine Medical Claim

Smita Singh

Tags