Bariatric Surgery Claim Rejection Overturned! Court Orders Rs 3.4 Lakh Payout
Surat: Signifying that an insurer cannot deny mediclaims without concrete evidence of pre-existing treatment, the Surat Consumer Disputes Redressal Commission (Additional) has directed an insurance company to reimburse around Rs 3.4 lakh for a 42-year-old policyholder's weight-loss surgery, which the company had previously denied.
The patient, a resident of Dabholi, Surat, underwent bariatric surgery for morbid obesity from January 27, 2022, to February 1, 2022, at a private hospital. He paid Rs 3,39,691 for the procedure and subsequently filed a claim under his Rs 5 lakh floater mediclaim policy, which was valid from August 24, 2021, to August 23, 2022. The patient as a policyholder maintained continuous health insurance coverage since 2010.
However, the insurance company- Cholamandalam MS General Insurance Co. Ltd. rejected the claim, citing non-disclosure of obesity at the time of purchasing the policy. The insurer stated; "The insured is suffering from obesity prior to the policy inception date as per the history recorded and documents. This was not declared in the proposal form."
The insurance company’s lawyer further argued that the insured had been obese for three years before the policy’s commencement but did not disclose this in the proposal form. During the investigation, the patient admitted that his weight had fluctuated between 115kg and 136kg over the past three years, and he had undergone surgery based on his doctor’s recommendation.
The complainant, represented by Advocates N H Navadiya and Jignesh Hariyani, countered that no prior medical treatment for obesity had taken place, and the insurer had no grounds to reject the claim based solely on an investigator’s report. The complainant filed his case on October 10, 2022.
After reviewing the arguments from both parties, the court ruled in favour of the patient, stating;
"No details on obesity were sought during the filling of the proposal form. The insurance firm also failed to prove that the complainant received treatment for obesity before commencement of the policy. Even after these facts, the company rejected the claim based on non-disclosure of facts. This is a deficiency in service on the part of the company, which is liable to pay the claim."
Recognizing the wrongful denial of coverage for medically necessary surgery, TOI reports that the court not only directed the insurance company to pay the full claim amount of Rs 3,39,691 but also ordered additional compensation of Rs 2,000 for harassment and Rs 2,000 for legal expenses.
