A penalty of Rs 25,000 on health insurance company Max Bupa was imposed by the District Consumer Dispute Redressal Forum for rejecting a 70-year-old cancer patient’s claim.
The firm has also to pay the complainant Rs 3.23 lakh, the money spent on treatment, with an interest of 9%.
“For the mental agony and harassment of the complainant, a penalty of Rs 25,000 was imposed on insurance company,” reads the order dated December 18 passed by the president of the forum, Subhash Goyal. Max Bupa was asked to pay the sum within 30 days of the order being passed. The rejection of mediclaim reimbursement, the forum observed, was tantamount to deficiency in service. “Thus we direct the company to reimburse the amount as spent by the complainant on his treatment i.e. to the tune of Rs 3.23 lakh along with interest of 9% per annum from the date of filing of the complaint to date of order,” read the order.
A Max Bupa spokesperson said the reimbursement was rejected in accordance with terms and conditions of the policy. “Our legal team is going through the order of the forum,” he said.
Kewal Pal Singh, a resident of DLF 2, had filed the complaint against Max Bupa in January 2015. Singh and his wife informed the forum they had had taken a medical insurance policy from National Insurance Company from 2004-2012 and paid an annual premium of Rs 77,254 without any break. In 2012, they upgraded their insurance and opted for ‘Family First Gold’ policy of Max Bupa with an assured cover of Rs 14 lakh. “They bought insurance from October 2012 to October 2013 by paying a premium of Rs 82,000. They renewed the policy till 2015,” said Harish Malhotra, Singh’s counsel.
On September 26, 2014, Singh claimed he was diagnosed with ‘disorder of calcium metabolis’ and was admitted to Sir Ganga Ram Hospital in Delhi. He informed the insurance company to avail of the cashless benefit, but it was rejected and he was asked to apply for reimbursement after paying the hospital.
Singh was at the hospital from September 26 to October 2, 2014. Thereafter, he was diagnosed with multiple myeloma and was admitted to Dr BL Kapur Hospital in Delhi on October 9 for treatment. Since then, he had had to make several visits to hospital for chemotherapy and had to pay the charges.
“He submitted documents multiple times but his claims for reimbursement were rejected. During this period, the policy was also renewed from October 25, 2014 to October 24, 2015,” said Malhotra, adding the claim was rejected on the account of non-disclosure of disorder of past 7-8 years.
After that, the company cancelled the medical insurance of the couple, he claimed. Singh then moved the forum.
“The rejection of the claim was not sustainable as the complainant has been obtaining the mediclaim policy since 2004… The exclusion clause regarding pre-existing conditions has got a condition for a waiting period of 48 months and in this case the mediclaim policy is continuous since 2004. Thus, the complainant is not covered under the exclusion clause,” the forum observed in its order.