Decided on January 07,2020

Amaresh Mishra Respondents


Deepa Sharma,J. - (1.) Arguments are heard in this matter. It is argued by the petitioner that procedure of LSG (Laproscopic Sleeves Gastrectomy) is a cosmetic procedure and hence not covered under the policy. It is also argued that while taking the policy, the respondent / complainant had concealed his medical history and, therefore, the findings of the State Commission in the impugned order suffers with illegality and is also perverse and liable to be set aside.
(2.) It is argued on behalf of the respondent / complainant that petitioner had not raised any objection in its written version filed before the District Forum that the complainant had taken the policy by fraud and by suppressing any pre existing disease. It is submitted that since this contention was never raised, the parties did not lead any evidence on this issue and there was no occasion for the District Forum and the State Commission to reflect upon this contention of the petitioner. It is argued for the first time in the revision petition and the petitioner cannot raise a fresh contention which is not solely legal but finding on which depends on the facts and circumstances of the case which needs to be proved before the trial court. It is submitted that the petitioner's arguments to this effect should be outrightly rejected. It is further argued that procedure of LSG is not a cosmetic procedure but was necessary for controlling the diabetes and, therefore, squarely covered under the policy. It is submitted that this Commission has limited jurisdiction and is not required to re-appreciate and reassess the evidence and substitute its own opinion to the State Commission's decision.
(3.) I have given my thoughtful consideration to the arguments of the learned counsel for the parties and have perused the record. Admittedly, the complainant had taken two policies. He was admitted in the Kirloskar hospital during the period 09.01.2011 to 18.01.2011 where he underwent LSG procedure for the treatment of his diabetes. He furnished his claim for the said treatment. He was discharged on 18.01.2011. He was again admitted in Belle Vue clinic as he was suffering with fever and underwent treatment and for that he submitted his claim under the second policy. Therefore, there were two separate claims under two separate policies owned by the complainant. Although District Forum after perusing the evidence on record dismissed the complaint, the State Commission after re-appreciating the evidence on record and hearing arguments of the parties, allowed the appeal of the complainant and issued following directions: "Insofar as Sampoorna Arogya Bima Policy excludes indemnity of all pre-existing diseases for the first three years since inception of the policy, it was futile on the part of the Appellant to expect any indemnity under this policy in respect of his treatment for LSG. It appears that Respondent No.4 is the competent authority to settle the claim for LSG treatment; whereas, concerned claim documents have admittedly been submitted before the Respondent No.2 with copy to the Respondent No.4. However, it seems that claim documents in respect of Appellant's treatment for Malaria have rightly been submitted with the Respondent No.2. In order to facilitate settlement of Appellant's claim for LSG, we deem it fit and proper to direct the Respondent No.2 to forward all relevant claim documents to the Respondents No.4 forthwith. ;

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