Consumer Forum Rejects Insurance Company’s Denial of Mediclaim Due to Obesity

In a notable judgment on May 28, the Indore Consumer Forum dismissed the plea of an insurance company to deny a mediclaim citing obesity as the reason. Rajendra Bhatia, a 63-year-old resident of Radha Nagar, Neelkanth Colony, Indore, successfully challenged the rejection of his ₹2.5 lakh mediclaim. The policy had been initiated 20 years ago with National Insurance Company.

The case surfaced when Bhatia experienced swelling in his legs and difficulty breathing on December 16, 2020. After initial examinations at a private hospital in Indore and subsequent medical advice, he was taken to a hospital in Mumbai. His stay in Mumbai lasted about ten days during which it was revealed through medical tests that he had accumulated water in his lungs.

Despite Bhatia’s condition, the insurance company denied his medclaim on August 9, 2021, on the grounds that obesity-related conditions were not covered under his policy. They highlighted that Bhatia was suffering from obesity hypoventilation syndrome, including conditions like hypoventilation and obstructive sleep apnea.

However, Bhatia contested this decision, pointing out that at the time of purchasing the medclaim in 2000 and even during the policy renewal from 2020 to 2021, the insurance company had not taken any particulars regarding his weight nor had expressed any objections to it. Intriguingly, his weight was around 100 kilograms when the policy was taken and was actually less at the time of claim rejection.

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The Consumer Forum found the insurance company’s documentation inadequate to prove that Bhatia’s treatment was solely for obesity. Furthermore, the forum directed the insurance company to compensate Bhatia with ₹2,33,550 for the medical expenses incurred, along with an interest of 9% from January 4, 2023, until payment completion within 45 days. Additionally, for mental anguish and litigation costs, the company must also pay ₹10,000 and ₹5,000 respectively.

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