The district consumer court in Pune has ruled that an insurance company cannot be held liable for deficient service when its policy agreement clearly excludes certain physical conditions from the reimbursement of medical expenses. A bench of VP Utpat and Kshitija Kulkarni rejected the complaint by a homemaker (name withheld) from Lullanagar who alleged that mediclaim service provider New India Insurance Company wrongfully rejected her claims against the expenses incurred on surgery for morbid obesity.
The company had resisted the complaint arguing that repudiation of her claim was based on a specific clause in the policy agreement that excluded morbid obesity from the reimbursement list. The complainant had subscribed to the company's mediclaim insurance policy for the period between 1 March 2012 and 28 February 2013, by paying a one-time premium of Rs 17,880 for Rs 5 lakh insurance cover.
In October 2012, she was admitted to a private hospital for surgeries of hernia as well as obesity. She incurred total expenses of Rs 5.80 lakh for the two surgeries conducted simultaneously. Later, when she submitted her claim, the company sanctioned surgery expenses of Rs 2.07 lakh for hernia, rejecting the claim amount for obesity.
The complainant had argued before the consumer court that her case was not that of a cosmetic surgery and that she was required to undergo surgery for hernia due to obesity, and that both health issues were connected. Obesity itself is a disease and the insurance company ought to have reimbursed the claim, she added.
The bench referred to the specific clause and observed: “It is crystal clear from the said clause that the expenses incurred for the surgery of obesity are excluded. The complainant was aware about the contents of the policy and she had entered into contract of insurance knowing she is not entitled for the same.” As such, the insurance company could not be held liable for deficient service, it ruled.
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