Claim payable if bariatric surgery is medical necessity

In cases where the bariatric surgery is performed for cosmetic purposes, the insurer is not liable to pay

Generally, bariatric surgery is performed for cosmetic purposes, or to lose weight to prevent an illness that may occur in the future. In such cases, the insurer is not liable to pay a claim for that surgery. However, in a unique twist, Advocate Ami Mandani argued that the maintainability of the claim would have to be considered from the angle of necessity of performing bariatric surgery. In a significant ruling, the South Mumbai District Consumer Forum agreed with the argument and held the insurer liable. 

Naresh Makani had purchased a mediclaim policy from New India Assurance. Makani underwent a lap sleeve gastrectomy and liver biopsy in Saifee hospital, for which he incurred a total expenditure of Rs 3,80,524. When he lodged a claim under the policy it was repudiated by M.D. Healthcare Services, the third-party administrator (TPA). The reason for rejecting the claim was that obesity treatment was not covered under the policy. Makani filed a complaint before the District Consumer Forum for South Mumbai. The insurer and the TPA jointly contested the case, arguing that repudiation was justified as treatment for morbid obesity was excluded under the policy. 

The Forum noted that Makani and his wife were first made to undergo several medical tests, and after being satisfied a policy was issued for Rs 5 lakh. Subsequently, in January 2013, Makani developed medical problems. After he underwent several medical tests, he was diagnosed as suffering from a liver problem. Due to the bad liver, Makani was putting on weight, which was in turn affecting his heart. Since he weighed 142.5 kilogram (kg) and had a height of 164 centimetre, his body mass was computed to be 48.5 kg per metre square.

Since his morbid obesity could not be brought down within a short span through diet and exercise, Malkani was advised to undergo a Lap Sleeve Gastrectomy and Liver Biopsy. He was operated at Saifee Hospital. 

Makani's advocate Ami Mandani argued that simply obesity was excluded under the policy, but morbid obesity arising out of medical conditions was not excluded. She contended that there can be no straightjacket formula for repudiating all claims for bariatric surgery, and that a claim ought to be paid when the surgery is performed specifically for the treatment of an ailment covered under the policy.

The Forum concurred with the submissions and noted that the medical evidence revealed that Makani was suffering from hyperuricemia, dyspnea, obstructive sleep apnea, and fatty liver, some of which are life threatening conditions. The Forum also relied on Makani's doctor's clarification that his condition was such that it had to be treated quickly and aggressively through a bariatric lap sleeve gastrectomy.

Accordingly, through its order of February 5, 2020, delivered by Presiding Officer Sneha Mhatre for the Bench along with D S Paradkar, the complaint was allowed. Since the claim was within the coverage limit of the policy issued by New India, the Forum held the insurer liable to pay the entire claim of Rs 3,50,412 along with 9 per cent interest from the date of repudiation. In addition, Rs 15,000 was awarded as compensation and Rs 10,000 as cost.

The writer is a consumer activist