Insurer Ordered to Pay Rs 3.4 Lakh After Wrongful Denial
Surat: In a significant ruling, the Surat Consumer Disputes Redressal Commission (Additional) has directed an insurance company to reimburse Rs 3.4 lakh to a 42-year-old policyholder after his claim for bariatric surgery was wrongfully denied. The court ruled that insurers cannot reject mediclaims without concrete evidence of pre-existing treatment.
Patient’s Claim Denied Over Alleged Non-Disclosure
The policyholder, a resident of Dabholi, Surat, underwent weight-loss surgery for morbid obesity from January 27 to February 1, 2022, at a private hospital. Despite having continuous health insurance since 2010 and a valid mediclaim policy of Rs 5 lakh, his claim of Rs 3,39,691 was rejected by Cholamandalam MS General Insurance Co. Ltd.
The insurer argued that the patient had not disclosed his obesity at the time of purchasing the policy, claiming that he had been obese for at least three years before the policy’s inception. The insurer cited medical history records as evidence of non-disclosure.
Court Finds Insurer Guilty of Deficiency in Service
The complainant’s lawyers, Advocates N H Navadiya and Jignesh Hariyani, countered that no prior medical treatment for obesity had occurred and that the rejection was based solely on an investigator’s report rather than factual evidence. The court found that:
- The insurance proposal form did not specifically ask about obesity.
- The insurer failed to prove that the complainant had received treatment for obesity before the policy commenced.
- Denying the claim based on non-disclosure was an unfair practice.
Recognizing the wrongful denial of a medically necessary surgery, the court ordered the insurance company to pay Rs 3,39,691, along with additional compensation of Rs 2,000 for harassment and Rs 2,000 for legal expenses.
