Bariatric Surgery Addressing Chronic Disease Is Life-Saving Procedure : Delhi State Commission Holds United India Insurance For Deficiency In Service

Brief Facts of the Case

The complainant, a member of SCBA, enrolled in a group medical insurance policy provided by the insurer. The policy covered pre-existing conditions. The complainant sought approval for cashless claims for dual surgeries for his father; gallbladder removal and bariatric surgery—performed in one session. However, the insurer's TPA approved only a partial amount for the gallbladder surgery and rejected the claim for the bariatric surgery, citing exclusions for obesity-related conditions. Despite providing all necessary certificates and documents, the insurer denied further claims, including extended hospital stay costs due to other chronic illnesses covered by the policy. The complainant filed a complaint before the District Commission, which allowed the complaint. It directed the insurer to refund Rs 5,03,231.80 as medical expenses, pay Rs 2,00,000 as compensation and Rs. 25,000 as litigation costs. Aggrieved, the insurer filed an appeal before the National Commission.

Contentions of the Insurer

The insurer contended that the District Commission's order was flawed and lacked merit. It was argued that the surgery in question was not for a life-threatening event but for cosmetics, making it ineligible for insurance claim. It urged the State Commission to take these averments into consideration.

Observations by the State Commission

The commission observed that the main issue was whether the insurer had been rightly held liable for deficiency of service by the District Commission. The case concerned a health insurance policy covering the complainant and family, under which the insurer denied a claim citing clause 4.9 of the policy terms. Clause 4.9 excludes coverage for conditions such as convalescence, psychiatric disorders, obesity-related treatments, and cosmetic procedures. However, case laws, including Oriental Insurance Co. Ltd. v. Kamleshbhai Udani and United India Insurance Co. Ltd. v. Sunil Gupta, established that morbid obesity is a serious disease requiring life-saving intervention, not cosmetic treatment. Similarly, the National Commission has repeatedly ruled that bariatric surgery addressing chronic diseases like diabetes or hypertension, combined with obesity, is a life-saving procedure and not excluded under standard policy terms. In the present case, the complainant's father underwent bariatric surgery as a prerequisite to gallstone removal. His medical condition, including morbid obesity and chronic illnesses, necessitated the procedure. Medical certificates confirmed that the surgery aimed to address life-threatening complications and was not for aesthetic purposes. The commission agreed with the District Commission that the insurer's denial of the claim was unjustified and amounted to a deficiency of service. It upheld the District Commission's order, affirming the surgery as life-saving and covered under the policy. The appeal by the insurer was dismissed without costs.

Case Title: United India Insurance Co. Ltd Vs. Devmani Bansal & Anr.

Case Number: F.A. No. 492/2023

Click Here To Read/Download The Order