Delhi State Commission Holds National Insurance Company Liable For Rejecting Claim Due To Bariatric Surgery

Brief facts:

The complainant along with her husband purchased a mediclaim policy from National Insurance Co. Ltd on 15.08.1999 and renewed it annually. During the subsistence of policy, the complainant fell and upon doctor's advice she was hospitalised for poorly controlled diabetes mellitus with hypertension and morbid obesity.

The complainant underwent Bariatric surgery at Fortis hospital on 18.07.2014 and paid Rs.4,01,250/-. Later, the complainant filed a detailed medical claim but the insurance company repudiated it vide letter dated 26.02.2015. Despite several request and sending legal notices, the issue remained unresolved.

Aggrieved, the complainant filed a complaint in the District Commission for deficiency in service. In reply, the insurance company argued that the claim was rejected as the policy excluded treatment for obesity and related complications. The hospital affirmed that they had conducted the surgery and a cheque of Rs.4,01,250/- was deposited with them.

Through an order dated 17.03.2020, the District Commission held that the insurance company was liable as the complainant underwent treatment due to serious health issues and not cosmetic purposes. Thus, the insurance company was directed to pay Rs. 4,10,633/- along with Rs.1,00,000/- as compensation and Rs. 10,000/- as litigation cost.

Dissatisfied by the decision of the District Commission, the insurance company filed an appeal before the State Consumer Disputes Redressal Commission, Delhi (“State Commission”).

Contentions of the National Insurance Co. Ltd:

The appellant contended that the District Commission did not consider the necessary documents and ignored that the complainant was treated for Laparoscopic surgery and no treatment was given to her for other diseases such as hypertension and diabetes etc.

Further, they alleged that prescription issued by the doctor was not authenticate and the District Commission overlooked the terms and conditions of policy.

Observations of the State Commission:

The Commission noted that the complainant was suffering from poorly controlled diabetes mellitus with Hypertension and morbid obesity and was evaluated for laparoscopic surgery. It also stated that the Bariatric surgery was important to prevent life-threatening diseases and the complainant did not undergo surgery to enhance her beauty at the age of 67 years.

Reliance was placed on New India Assurance Company Ltd and another versus Anita Chaudhary and another reported in 2016(4) CPJ 378, where the compensation was awarded for surgery due to morbid obesity. Further, in United India Insurance Co. Ltd versus Sunil Gupta and another reported in 2015(2) CLT 318 it was held that Bariatric surgery was not aimed at improving physical appearance but to prevent health complications.

Therefore, the appeal was dismissed and the decision of the District Commission was upheld.

Case Title: National Insurance Co. Ltd. Vs. Smt. Shanta Devi & Ors

Case No: First Appeal No.-137/2020

Date of Pronouncement: 06.12.2024

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