State Consumer Disputes Redressal Commission
The New India Assurance Co. Ltd., vs 1.T.R. Ramdass on 2 February, 2024
1
BEFORE THE TELANGANA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION : HYDERABAD.
F.A.No. 563 OF 2018
AGAINST ORDERS IN C.C.196/2015
DISTRICT CONSUMER COMMISSION-II, HYDERABAD
Between:
The New India Assurance Company Limited,
Rep. by it's Branch, 9th Floor Parisharam Bhavan,
Basheerbagh, Hyderabad.
......Appellant/ Opposite Party No.1
And:
1.T.R.Ramdass, S/o T.R.Rajagopalam, Age : 55 years, Occ.: Engineer, R/o 2-2-647/110, Central Excise Colony, Bagh Aamberpet, Hyderabad.
........Respondent No.1 / Complainant
2. The Manager, MD, India Health Care Services TPAP Pvt., Ltd., No.103, 1st Floor, 6-3-883/A, Imperial Plaze, Panjagutta, Hyderabad-82.
........Respondent No.2 /Opposite Party No.2 Counsel for the Appellant/Opposite Party No.1 :
M/s. I. Mammu Vani Counsel for the Respondent No.1/Complainant :
M/s. KR Koteswara Rao Counsel for the Respondent No.2/Opposite Party No.2 :
Set ex-parte QUORUM :
HON'BLE SRI V.V.SESHUBABU, MEMBER-JUDICIAL & HON'BLE SMT R.S. RAJESHREE, MEMBER - (NJ) FRIDAY, THE 02nd DAY OF FEBRUARY TWO THOUSAND TWENTY FOUR ********** Order : (PER HON'BLE SRI. V.V.SESHUBABU, MEMBER - JUDICIAL)
1. The appeal is filed by the opposite party No.1 under section 15 of the C.P.Act, 1986 aggrieved by the order of District Consumer Disputes Redressal Commission -II, Hyderabad in CC 196/2015 dated 1.0.08.2018, whereunder the opposite parties No.1 & 2 are directed to pay with joint and several liability a sum 2 of Rs.2,00,000/- with interest at 9% per annum from 03.04.2014 till actual payment; to pay Rs.15,000/- as compensation and Rs.10,000/- as costs within 30 days, failing which all the amounts would carry interest at 9% per annum till realization.
2. The brief averments of the complaint in CC 196/2015 are that the complainant and his wife have taken medi-claim policy, bearing No.810200/34/13/01/00000651 from Opposite Party No.1; that during January' 2014 wife of complainant by name Smt.S.Radha, was admitted in the Kokilaben Dhirubhai Ambani Hospital, Mumbai, for the treatment of morbid obesity with comorbidities as per the advice of the specialist and was operated and discharged on 17.03.2014 and spent a sum of Rs.5,00,000/-;
that the complainant made a claim for reimbursement after reaching Hyderabad; that Opposite Party No.2 is the agency working for opposite party No.1; that a letter was issued by the opposite party No.1 stating that the complainant is not entitled for the claim in view of the terms and conditions of the policy which excludes treatment for morbid obesity and its complications; that the complainant obtained a clarification from specialist surgeon, who stated that as the patient gained weight due to restriction in movements caused by arthorities which led to weight gain; that inspite of the said clarification, the claim was not settled; hence, the claim for Rs.2,00,000/- with interest @ 12% per annum.
3. The brief averments of the written version of the Opposite Party No.1 is that the complaint is not maintainable either on facts or under law; that the complaint is barred by time; that Opposite Party No.2 is the agent of Opposite Party No.1; that they have issued policy covering the risk of complainant and his wife, commencing from 16.06.2013 to 15.06.2014 for Rs.2,00,000/-; that as per the exclusion Clause 4-4.6 of the terms and conditions of the policy, the insurer is not liable to pay the treatment expenses incurred for morbid obesity and its complications.; that the specialist opinion was obtained 3 subsequent to the repudiation of claim, to suit the needs of complainant and there is no basis to support the same in the medical record; that the claim was rightly repudiated. With this requested to dismiss the complaint with exemplary costs.
4. Before the Forum below, complainant filed evidence affidavit as PW1 and got marked Ex.A1 to A6. Mr.Balwinder Singh, Regional Manager, working in the Opposite Party No.1 filed evidence affidavit as RW1 and got marked Ex.B1. Written arguments filed for both sides and they have advanced the oral submissions.
5. The Forum below settled the following points for discussion, viz:
(a) Whether any deficiency of service was there on the part of the opposite parties as claimed in the complaint?
(b) Whether the complainant is entailed for the reliefs sought for?
(c) To what relief?
6. Having gone through the available material on record, the Forum below passed the order as stated supra. Aggrieved by the same, the present appeal is filed with the following grounds:-
The order of the Forum below is contrary to law weight of evidence in the probabilities of the case. The Forum below failed to appreciate the case law, cited in proper prospective.
The Forum below failed to appreciate exclusion clause 4-4.6 of the terms and conditions of the policy which is very clear that the insurer is not liable to pay the treatment expenses for co-morbidity and its complications.
With these grounds and others that will be urged at the time of arguments requested to set aside the order of the Commission below and to dismiss the complaint.4
7. Now the point for determination is whether the impugned order by the Commission below is sustainable under law?
8. Point :- Nobody is examined and no document is marked before this Commission. For the sake of convenience the parties will be addressed as they arrayed in the complaint. It is the contention of opposite parties that in view of the exclusion Clause 4-4.6 of the terms and conditions of Ex.B1 policy, the insurer is not liable to pay any treatment expenses for the morbid obesity and co-morbidities. It is also the contention that the operation undergone by the wife of PW1 is a cosmetic surgery with beauty consciousness even there was no requirement for such surgery, that the opinion of the specialist was obtained subsequent to the repudiation of claim only to suit the requirements of PW1.
9. As per the Ex.A6=B1 policy, the wife of the complainant was aged 50 years, by the time of taking policy in the year 2013. In view of her age, it is too much for the opposite parties to argue that she had undergone the morbid obesity operation with beauty consciousness. It is also to be observed that PW1 and his wife are taking medi-claim policies from the opposite party No.1 from several years and Ex.A6=B1 is in continuation of the policies. If really, wife of PW1 was of beauty consciousness, she might have undergone the operation long back. So, we cannot appreciate the argument of opposite party No.1.
10. As per Ex.A1, Discharge Summary, wife of PW1 went to the hospital with past history of arthritis since few years, but not on any medication; K/C/O hypertension on irregular treatment; K/C/O obstructive sleep apnoea. Whereas, the chief complaints are morbid obesity with C/O weight gain after menopause, associated with difficulty in walking - no other complaints and admitted for surgery. It is the argument of the 5 opposite parties, the Ex.A1 was obtained to suit the requirements of PW1 and when the chief complaint is not relating to arthritis, mentioning the same in the past history is an afterthought.
11. It is known to one and all that obesity leads to several health complications and one among the same is the problem with knees and arthritis due to weight gain. Therefore, the operation undergone by PW1 for morbid obesity is only to improve her health condition but not for beautification. The Forum below discussed the case law submitted by the complainant in proper perspective and nothing wrong was done while drawing inferences. Complainant also relied upon the following Judgments viz (i) Hon'ble State Consumer Disputes Redressal Commission, Maharasthra in the United India Insurance vs. K.P.Desai, dated 31.01.2013 in First Appeal No.A/04/843; (ii) SCDRC,Chandigarh, in Ashwini Goel vs. New India Assurance Company, dated 13.12.2013 in FA NO.1687/2010; (iii) Hon''le NCDRC, in United India Insurance Company Limited through the Regional Manager, vs. Sunil Gupta and another in RP No.4558/84, dated 07.04.2015; (iv) SCDRC, Chandigarh, in Baldev Krishan vs. Ashok Kumar Singla, dated 25.10.2018 in FA NO.778/2017.
12 Out of the four, the cases 2 to 4 relates to claims made for morbid obesity and related complications. The first one relates to lasik surgery to the eyes. In all the cases uniformly observed that the operations were conducted for other complications and they cannot be considered as cosmetic surgeries. More specifically it is observed that morbid obesity would lead to severe health complications, thereby allowed the complaints and dismissed the appeals preferred by the Insurance Companies. Therefore, we are of the view that there is no necessity to take different opinion in the case on hand regarding the surgery performed on wife of PW1. Whether arthritis is the first or obesity, pales in to insignificance 6 when morbid obesity surgery was performed on a patient with lot of weight gain that too at her age of 51 years. So, the point is answered against the appellant.
13. In the result, the appeal is dismissed with costs of Rs.10,000/- (Rupees ten thousand only) by confirming the order of the District Consumer Commission-II, Hyderabad in CC 196/2015, dated 10.08.2018.
Time for compliance is 30 days from the receipt of this order.
The Respondent No.1/Complainant is permitted to withdraw the statutory deposit of Rs.25,000/- made by the Appellant/OP No.1 with accrued interest, after the lapse of appeal time.
Sd/- Sd/-
MEMBER-JUDICIAL MEMBER (NJ)
Dated : 02.02.2024
*AD