DCDRC Orders Max Bupa Health Insurance To Compensate Complainant For Rejecting Valid Claim For Hospitalization

DCDRC Orders Max Bupa Health Insurance To Compensate Complainant For Rejecting Valid Claim For Hospitalization

Directs it to pay Rs.24,565 as hospital expenses, Rs.20,000 for mental agony and Rs.5000 litigation costs to the complainant

The District Consumer Disputes Redressal Commission (DCDRC) - VII, Southwest Delhi, has held Max Bupa Health Insurance Co Ltd liable for deficiency in services for wrongfully repudiating a genuine claim based on unfounded pre-existing conditions.

The complainant shifted her insurance policy to Max Bupa from New India Assurance Co Ltd.

The agent assured her that the continuity of her insurance coverage would remain unaffected. Subsequently, she renewed her Mediclaim policy by paying Rs.16,704 and Rs.19,014. The policy covered her and her son for a total sum insured of Rs.20 lakh.

Despite renewals and payments, the complainant claimed that the insurance company rejected her claim for medical expenses incurred for Rs.24,565 following her hospitalization at the Holy Family Hospital for abdominal pain and bleeding.

The woman stated that she promptly informed the insurance company about her admission to seek cashless facility approval, which the insurance company denied. It forced her to self-finance her medical bills.

Despite submitting all necessary documents, the insurance company allegedly rejected her claim citing Clause 4 (A) of the policy's terms and conditions, reasons for which were not communicated to her earlier.

Faced with an unforeseen situation, the woman approached the DCDRC and filed a consumer complaint against the insurance company, which did not appear before the Commission for the proceedings.

The District Commission bench comprising Suresh Kumar Gupta (President), Harshali Kaur (Member) and Ramesh Chand Yadav (Member) noted that the insurance company rejected the complainant's claim under clause 4 (A) of the policy terms, stating that she failed to disclose a pre-existing condition of heavy bleeding, which allegedly existed for four to five years as per the submitted documents.

However, upon reviewing the discharge summary, the Commission noted that there was no history of heavy bleeding during her hospitalization. The admission notes indicated that her Last Menstrual Period (LMP) was on 09.09.2014, and she was admitted for Abnormal Uterine Bleeding (AUB) for Hysteroscopy and Dilation and Curettage (D&C).

The DCRDC held that the rejection of the claim based on undisclosed pre-existing conditions was unfounded, as there was no documented history of such a condition at the time of admission. If the complainant suffered from prolonged heavy bleeding (as claimed by the insurance company), during her hospitalization, the medical staff would have noted it.

Thus, the Commission directed the insurance company to pay Rs.24,565 to the complainant. It was further ordered to pay a compensation of Rs.20,000 for the mental agony and distress caused to her for an unjustified rejection of the claim and Rs.5000 for litigation costs.