Consumer Commission Orders Max Bupa To Reimburse Wrongfully Denied Claim

Consumer Commission Orders Max Bupa To Reimburse Wrongfully Denied Claim

The District Consumer Disputes Redressal Commission – X, New Delhi bench, consisting of President Monika Aggarwal Srivastava, Member Dr. Rajender Dhar, and Member Ritu Garodia, ruled in favour of a policyholder against Max Bupa Health Insurance Co. Ltd. The case involved the rejection of a medical claim by Max Bupa, which the District Commission deemed wrongful.

An unnamed complainant purchased a health insurance policy from Max Bupa and paid the required premiums. Following breathing difficulties, the complainant received treatment at Neo Hospital, incurring expenses of ₹48,923. This cashless claim was processed and approved by Max Bupa.

However, the complainant's condition worsened, leading to admission to the ICU of Max Super Specialty Hospital with bills totalling ₹5,62,984. This subsequent claim was denied by Max Bupa.

Feeling aggrieved, the complainant filed a consumer complaint against Max Bupa with the District Commission. Max Bupa defended their decision, citing exclusion clause 8.4 of their policy terms and conditions (T&C). This clause excluded coverage for expenses related to screening, counselling, and treatment of complications associated with autoimmune disorders. Additionally, Max Bupa claimed the complainant never submitted the ₹5,62,984 medical bill.

The District Commission considered the complainant's medical history, which revealed diagnoses of Type 2 Diabetes Mellitus (DM), Hypothyroidism, and Myasthenia Gravis. These conditions significantly impacted the complainant's health.

The Commission highlighted a key inconsistency. Max Bupa approved the initial claim at Neo Hospital, where the complainant was diagnosed with both respiratory infection and Myasthenia Gravis. However, they rejected the second claim despite the same diagnosis (Myasthenia Gravis) at Max Super Specialty Hospital. This raised doubts about the company's consistent application of policy terms.

Max Bupa argued that the initial treatment addressed a respiratory infection, not Myasthenia Gravis. The District Commission found Max Bupa's explanation lacking clarity regarding the differing treatments, especially since both hospitals reached the same final diagnosis. This inconsistency in treatment and claim processing further cast doubt on Max Bupa's adherence to the policy.

The DCDRC ruled in favour of the complainant, holding Max Bupa liable for deficiency in services and consequently directed them to reimburse the complainant for the total medical bills of ₹5,80,984 (including the initial claim), pay interest of 9% on the total claim amount from the discharge date until payment, and additionally pay ₹20,000/- as compensation and ₹5,000/- as litigation costs to the Complaint.