Page 50 - Insurance Times September 2020

Advocate Ami Mandani argued that the maintainability of Since his morbid obesity could not be brought down within
the claim would have to be considered from the angle of a short span through diet and exercise, Malkani was ad-
necessity of performing bariatric surgery. In a significant vised to undergo a Lap Sleeve Gastrectomy and Liver Bi-
ruling, the South Mumbai District Consumer Forum agreed opsy. He was operated at Saifee Hospital.
with the argument and held the insurer liable.
Makani's advocate Ami Mandani argued that simply obe-
Naresh Makani had purchased a mediclaim policy from New sity was excluded under the policy, but morbid obesity aris-
India Assurance. Makani underwent a lap sleeve gastrec- ing out of medical conditions was not excluded. She con-
tomy and liver biopsy in Saifee hospital, for which he in- tended that there can be no straightjacket formula for re-
curred a total expenditure of Rs. 3,80,524. When he lodged pudiating all claims for bariatric surgery, and that a claim
a claim under the policy it was repudiated by M.D. ought to be paid when the surgery is performed specifically
Healthcare Services, the third-party administrator (TPA). The for the treatment of an ailment covered under the policy.
reason for rejecting the claim was that obesity treatment
was not covered under the policy. Makani filed a complaint The Forum concurred with the submissions and noted that
before the District Consumer Forum for South Mumbai. The the medical evidence revealed that Makani was suffering
insurer and the TPA jointly contested the case, arguing that from hyperuricemia, dyspnea, obstructive sleep apnea, and
repudiation was justified as treatment for morbid obesity fatty liver, some of which are life threatening conditions.
was excluded under the policy. The Forum also relied on Makani's doctor's clarification that
his condition was such that it had to be treated quickly and
The Forum noted that Makani and his wife were first made
to undergo several medical tests, and after being satisfied aggressively through a bariatric lap sleeve gastrectomy.
a policy was issued for Rs. 5 lakh. Subsequently, in January Accordingly, through its order of February 5, 2020, deliv-
2013, Makani developed medical problems. After he under- ered by Presiding Officer Sneha Mhatre for the Bench along
went several medical tests, he was diagnosed as suffering with D S Paradkar, the complaint was allowed. Since the
from a liver problem. Due to the bad liver, Makani was claim was within the coverage limit of the policy issued by
putting on weight, which was in turn affecting his heart. New India, the Forum held the insurer liable to pay the
Since he weighed 142.5 kilogram (kg) and had a height of entire claim of Rs. 3,50,412 along with 9 per cent interest
164 centimetre, his body mass was computed to be 48.5 from the date of repudiation. In addition, Rs. 15,000 was
kg per metre square. awarded as compensation and Rs. 10,000 as cost. T

Vital Launches Next-Gen Group Health Plans for SMEs at Monthly Premium of INR 199
India’s leading online health and wellness marketplace and insurance provider Vital today launched its group health
insurance plans (in collaboration with leading insurers) that provide next-gen employee health benefits packaged into
Comprehensive Health Plans. These plans are specifically designed to cater to small and medium business owners in
India who are looking to secure their employees’ health with affordable and all-inclusive healthcare packages. At a
time when health concerns have taken the front seat in our lives, health plans like these are a great way for organi-
zations to give their employees one less thing to worry about for sure.
Vital’s Group Health Insurance plans also have convenient payment options that include monthly premiums starting
from INR199 per employee. The company also said that it has signed up several next gen employers, including Tripoto,
Little Black Book (LBB), TrulyMadly, Rusk Media, Falcon Brick,Zypp and Skylo, for its new plans.
The group health insurance plans from Vital not only include comprehensive health insurance benefits, but also offer
access to Vital’s curated healthcare marketplace for offers on doctor consultations, pharmacies, mental health pack-
ages, dental packages and even maternity benefits.
For employers, a digital dashboard lets them track and maintain their employees' plan details with instant policy issu-
ance, single-click addition and removal of members and easy tracking of payments. Employees, too, have a seamless
experience on the mobile web app from where they can manage their coverage and benefits, by their ecard and
policy anytime as well as a marketplace with offers from leading health & wellness brands curated just for them.
“We have created truly next generation group health insurance packages platform with comprehensive features and
benefits for both business organizations and their employees. These plans are specially designed to protect cash flows
for smaller organizations and are further accessible seamlessly to both employers and employees via an all-digital,
mobile-first experience,” said Jayan Mathews, Co-Founder and Chief Product Officer of Vital.

46 The Insurance Times, September 2020