Mumbai: Consumer forum orders insurance company to refund ₹3.97 lakh with interest to woman for rejecting morbid obesity surgery claim

Mumbai: The District Consumer Disputes Redressal Commission, south Mumbai, has ordered a refund of ₹3.97 lakh with 9% interest to a woman whose claim for morbid obesity surgery was rejected by the United India Insurance Company Ltd. Ruling in the complainant’s (the patient’s husband) favour, the commission stated that morbid obesity is not the same as obesity and surgery for it is not a cosmetic treatment. It also ordered payment of ₹25,000 towards mental agony and litigation cost.

Insurance company could not prove its case that surgery wasn’t required

The commission said that the insurance company could not prove its case that surgery wasn’t required nor that it was under an exemption clause. The order came in the complaint by Malad resident Mahesh Halwai against the insurance firm’s regional office and divisional offices in south Mumbai. Halwai was an employee of the firm, which had taken out a group insurance policy for its employees. Halwai’s wife was also covered under it.

In April 2012, she attended a health camp where she was advised to lose weight. Later, she was again given the same advice in September 2013 by Cancer Patients and Associations. Around that time, she weighed 125kg, and in the next three months her weight increased to 135kg. This further led to arthritis, breathing problems and non-routine urinary problems, with doctors advising lap gastric bypass. She was operated at Saifee Hospital in November 2014 and was admitted for a month.

Claim rejected

When her husband sought the claim money, it was rejected. The insurance company contended that no proof was submitted of a doctor suggesting such a surgery and that being an employee of the company, he knew the terms and conditions of the policy. Later, the ombudsman too rejected the claim. Halwai then filed a complaint with the consumer commission. 

During the hearing, Halwai provided a letter from the doctor which stated that the surgery was required as it could have led to other health issues like diabetes, blood pressure, heart ailments and hypertension. He informed the commission that the problem was due to hormonal changes due to metabolic syndrome and that morbid obesity is a serious disease associated with severe complications which may be life threatening.   

Citing various case laws which stated that rejecting the claims was becoming routine, the commission said that the complainant had proved that the surgery was only to ensure that she did not have any further ailments. The commission then directed that its order be implemented within 30 days.