A Kerala consumer commission has ordered National Insurance Company to reimburse a claim for bariatric surgery, recognising its medical necessity beyond weight loss, challenging insurers’ exclusion policies on obesity treatments.
A consumer commission in Ernakulam, Kerala, has ordered National Insurance Company to reimburse a health insurance claim it had rejected after classifying a hospital procedure as treatment for obesity alone. The panel found that the surgery was linked to a wider set of medical problems, including weight gain, high blood pressure, breathlessness and knee pain, and said the insurer had no medical evidence to support its refusal.
According to the decision reported by The Economic Times, the policyholder had bought family cover in February 2020 for a premium of about Rs 22,000. In June that year, the spouse was admitted to Lakeshore Hospital in Kochi and underwent a laparoscopic sleeve gastrectomy, with the bill totalling Rs 3,20,266. The insurer rejected the claim, arguing that the policy excluded obesity and conditions arising from it, as well as weight-control treatment.
The complainant first took the matter through the insurer’s grievance process and then to the Insurance Ombudsman, but both avenues failed. Before the consumer commission, the family said medical records showed a longer history of health concerns, not a cosmetic or stand-alone slimming procedure. The commission accepted that argument, noting that the insurer had not produced expert medical opinion of its own to prove the surgery was purely for obesity.
The panel also dismissed the company’s reliance on an Insurance Regulatory and Development Authority of India circular issued in 2019. It said the document took effect only from 1 October 2020 for new policies, while this cover was issued on 3 February 2020. On that basis, the bench held that the rejection amounted to an unfair trade practice and ordered the company and co-respondents to pay Rs 3,20,266, plus Rs 20,000 for mental agony and Rs 10,000 towards costs. If payment is delayed beyond 45 days, the treatment sum will carry 7.25% annual interest from the date the complaint was filed.
The ruling fits a broader pattern in which consumer forums have challenged insurers over their treatment of weight-loss procedures. In a separate case reported by The New Indian Express in May, a Hyderabad consumer commission directed Star Health and Allied Insurance to reimburse more than Rs 3.35 lakh after rejecting a knee surgery claim as a pre-existing condition. Other recent decisions cited by regional newspapers show consumer panels in Kerala, Gujarat and Surat scrutinising whether bariatric or metabolic surgery should be treated as elective weight-loss treatment or as medically necessary care.
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