Case Title: Hari Mohan vs Max Bupa Health Insurance Co. Ltd.
The New Delhi branch of the District Consumer Disputes Redressal Commission–X, composed of Monika Aggarwal Srivastava (President), Dr Rajender Dhar (Member), and Ritu Garodia (Member), has held Max Bupa Health Insurance Company responsible for unjustly denying a valid medical claim. The Commission observed that the insurer approved one claim but refused another similar one, creating suspicion about its consistent adherence to the policy terms.
Here’s the story: The complainant, Hari Mohan, purchased a health insurance policy from Max Bupa, for which he paid the necessary premiums. Later, due to breathing difficulties, he sought treatment at Neo Hospital, where he incurred expenses of Rs. 48,923. He filed a cashless claim, which Max Bupa processed. However, trouble arose when Hari Mohan had to be admitted to the ICU of Max Super Specialty Hospital, where he racked up bills amounting to Rs. 5,62,984. Max Bupa rejected this claim. Feeling wronged, Mr. Mohan filed a complaint against the insurance company at the District Commission.
Max Bupa defended its decision by stating that the second treatment’s pre-authorization request was denied based on an exclusion clause in the policy’s terms and conditions. This clause stated that expenses related to screening, counselling, and treatment of complications connected with autoimmune diseases fall under ‘permanent exclusion.’ The insurer also contended that Mr. Mohan did not submit the claim for the Rs. 5,62,984 medical bills.
The District Commission analyzed Mr. Mohan’s medical history, which showed a diagnosis of DM Type 2, Hypothyroidism, and Myasthenia Gravis, which significantly affected his health. After his first admission at Neo Hospital, where he was diagnosed with a respiratory infection and Myasthenia Gravis, Max Bupa processed a cashless claim. However, despite being discharged against medical advice, Mr. Mohan continued to suffer from breathing difficulties, leading to his readmission in Max Health Care Hospital, where he was diagnosed with Myasthenia Crisis with respiratory failure type 1.
The District Commission found it suspicious that the insurance company approved the initial claim but denied the subsequent one. The insurer argued that during the first hospitalization, Mr. Mohan was treated for a lower respiratory tract infection and not for Myasthenia Gravis, while the second hospitalization involved treatment for Myasthenia Gravis. However, the District Commission pointed out that both hospitals reached the same final diagnosis, and the insurance company’s differing treatments raised doubts about its adherence to the policy terms.
For this reason, the District Commission declared Max Bupa liable for deficiency in services. It ordered the insurance company to reimburse Mr. Mohan for the medical bills totalling Rs. 5,80,984, plus 9% interest from the discharge date until realization. Further, it instructed Max Bupa to pay Rs. 20,000 as compensation and Rs. 5,000 as litigation costs to Mr. Mohan.
This ruling affirms the crucial principle that insurance companies must consistently adhere to their policy terms, treat similar claims similarly, and provide clear justifications for their decisions. Any deviation from this principle could be seen as a deficiency in service, warranting compensation.
