The Delhi State Commission, led by Justice Sangita Dhingra Sehgal, has ruled that bariatric surgery for chronic diseases is a life-saving procedure and cannot be excluded from standard policy terms. The case involved a group medical insurance policy provided by the insurer, which covered pre-existing conditions. The complainant, a member of the Supreme Court Bar Association, sought approval for cashless claims for his father’s dual surgeries: gallbladder removal and bariatric surgery. However, the insurer’s Third-Party Administrator (TPA) approved only a partial amount for the gallbladder surgery and rejected the claim for the bariatric surgery, citing exclusions for obesity-related conditions.
The complainant filed a complaint before the District Commission, which allowed the complaint and directed the insurer to refund Rs 5,03,231.80 as medical expenses, pay Rs 2,00,000 as compensation, and Rs 25,000 as litigation costs. The insurer appealed to the National Commission, arguing that the surgery was not for a life-threatening event but for cosmetic purposes, making it ineligible for an insurance claim.
The State Commission observed that the main issue was whether the insurer had been rightly held liable for deficiency of service by the District Commission. The commission noted that the policy terms excluded coverage for conditions such as convalescence, psychiatric disorders, obesity-related treatments, and cosmetic procedures. However, the commission relied on case laws, including Oriental Insurance Co. Ltd. v. Kamleshbhai Udani and United India Insurance Co. Ltd. v. Sunil Gupta, which established that morbid obesity is a serious disease requiring life-saving intervention, not cosmetic treatment.
The commission also noted that the National Commission has repeatedly ruled that bariatric surgery addressing chronic diseases like diabetes or hypertension, combined with obesity, is a life-saving procedure and not excluded under standard policy terms. In this case, the complainant’s father underwent bariatric surgery as a prerequisite to gallstone removal, and his medical condition, including morbid obesity and chronic illnesses, necessitated the procedure.
The commission agreed with the District Commission that the insurer’s denial of the claim was unjustified and amounted to a deficiency of service. The commission upheld the District Commission’s order, affirming that the surgery was life-saving and covered under the policy. The appeal by the insurer was dismissed without costs. This ruling emphasizes that bariatric surgery for chronic diseases is a life-saving procedure that cannot be excluded from standard policy terms, and insurers must cover such procedures under their policies.