Case Title: Hari Mohan vs Max Bupa Health Insurance Co. Ltd.
Summary
Max Bupa Health Insurance Co. was found accountable for the wrongful rejection of a valid medical claim by the District Consumer Disputes Redressal Commission–X, New Delhi panel. The panel observed that the Insurance Company approved one claim but rejected another similar claim, raising concerns about the consistent adherence to the policy terms. The Complainant, who had a medical history including DM Type 2, Hypothyroidism, and Myasthenia Gravis, was initially authorized by the Insurance Company but later rejected. The District Commission found that the Insurance Company did not provide sufficient clarification regarding the dissimilar treatments, despite both institutions reaching the same final diagnosis. The Complainant was instructed to reimburse Rs. 5,80,984/- in medical expenses, with a 9% interest rate from the date of discharge until realization. The Complainant was also directed to receive Rs. 20,000/- in compensation and Rs. 5,000/- in litigation costs.
About the case
Max Bupa Health Insurance Co. was found accountable for the wrongfully rejection of a valid medical claim by the District Consumer Disputes Redressal Commission–X, New Delhi panel, which is comprised of Monika Aggarwal Srivastava (President), Dr. Rajender Dhar (Member), and Ritu Garodia (Member). The Commission observed that the Insurance Company approved one claim but rejected another similar claim, which raised concerns about the consistent adherence to the policy terms.
The Complainant acquired a health insurance policy from the Max Bupa Health Insurance Co. Ltd. (“Insurance Company”) and submitted the necessary premiums. The Complainant subsequently sought medical attention at the Neo Hospital for respiratory difficulties, resulting in expenses of Rs. 48,923/-. A cashless claim was submitted by the Complainant, and it was processed accordingly. Nevertheless, the Complainant was subsequently admitted to the ICU of Max Super Specialty Hospital, where he incurred expenses totaling Rs. 5,62,984/-. This claim was denied by the insurance company. The Complainant lodged a consumer complaint against the Insurance Company with the District Consumer Disputes Redressal Commission – X, New Delhi (“District Commission”), feeling aggrieved.
The Insurance Company responded by asserting that the pre-authorization request for the second treatment was denied due to the exclusion clause 8.4 of the policy’s terms and conditions. The clause stipulated that expenses associated with the screening, counseling, and treatment of complications associated with autoimmune disorders are classified as “permanent exclusion.” Furthermore, the Insurance Company contended that the Complainant failed to submit the claim for medical expenses totaling Rs. 5,62,984/-.
The District Commission observed that the Complainant’s medical history included a diagnosis of DM Type 2, Hypothyroidism, and Myasthenia Gravis, which had a substantial impact on his health. The Insurance Company effectively processed a cashless claim after the Complainant was diagnosed with Myasthenia Gravis and a respiratory infection at Neo Hospital during the patient’s initial hospitalization. Despite being discharged against medical advice, the Complainant continued to experience breathing difficulties, which resulted in his readmission to Max HealthCare Hospital. There, he was diagnosed with Myasthenia Crisis with respiratory failure type 1.
The claim was initially authorized by the Insurance Company, according to the District Commission, but the subsequent claim was rejected. It was maintained that this raised concerns about the company’s consistency in its actions.
The Insurance Company argued that the Complainant received treatment for a lower respiratory tract infection during the initial hospitalization, but not for Myasthenia Gravis. Treatment for Myasthenia Gravis was administered during the second hospitalization in contrast. Nevertheless, the District Commission determined that the Insurance Company did not provide sufficient clarification regarding the dissimilar treatments, despite the fact that both institutions reached the same final diagnosis. The District Commission maintained that the Insurance Company’s compliance with the policy’s terms was called into question by the inconsistency in claim processing and treatment.
Consequently, the Insurance Company was held accountable by the District Commission for the deficiency in services. As a result, the Complainant was instructed to reimburse Rs. 5,80,984/- in medical expenses, with a 9% interest rate from the date of discharge until realization. Furthermore, the Complainant was directed to receive Rs. 20,000/- in compensation and Rs. 5,000/- in litigation costs.
