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Ahmedabad: A 13-year-old girl underwent a spine surgery, but, looking at her weight, the insurance company construed it as obesity treatment and denied the health insurance claim. The teenager was admitted to a private hospital specialising in spine treatment in Ahmedabad in March 2019 and underwent surgery for L5-S1 prolapsed intervertebral disc (PID), a condition affecting the lower spine. The family had a health cover from the Oriental Insurance Company Ltd, and the parents claimed reimbursement of Rs 1.6 lakh spent for the treatment. The company relied on medical records showing that the girl weighed 72 kg and had a body mass index (BMI) of 26.1, which it considered overweight.
It has taken a consumer commission to order the insurer to reimburse the medical bills along with compensation for causing harassment to the family. She had been complaining of pain in her lower back radiating to her left leg. The insurer rejected the claim citing a policy clause that excluded treatment for obesity. The parents unsuccessfully tried to convince the insurer that the surgery was not aimed at weight reduction. The parents finally approached the District Consumer Disputes Redressal Commission, Ahmedabad (Additional), where the insurer, considering the discharge papers and weight of the teenager, asserted that she underwent a weight reduction programme and the health insurance policy excludes any such treatment.
It also additionally ordered payment of Rs 4,000 towards litigation costs and compensation. Because of her obesity, not only this, her pain was also not caused. Therefore, the insurance company’s denial of claim to the complainants on the grounds that it was obesity related treatment is improper and unreasonable.”
No treatment was given in the hospital related to obesity, according to the doctor’s certificate. Its doctors also stated that the cause of the disc problem was idiopathic, meaning that no specific cause had been identified, and that her problem was not caused by her obesity. After the hearing, the commission ruled in favour of the complainant and directed the insurer to pay the mediclaim. Terming it a deficiency in service, the commission stated, “The treating doctor has in clear terms informed that the surgery was not undertaken to treat her obesity.
Before the commission, the hospital maintained that the patient was treated exclusively for her spinal condition and had not received any treatment for obesity.