Inconsistency In Treating Similar Medical Insurance Claims, New Delhi District Commission Holds Max Bupa Health Insurance Co. Liable

Brief Facts:

The Complainant purchased a health insurance policy from the Max Bupa Health Insurance Co. Ltd. (“Insurance Company”) and paid the required premiums. Subsequently, the Complainant sought medical attention due to breathing difficulties at the Neo Hospital, and incurred expenses amounting to Rs. 48,923/-. The Complainant applied for a cashless claim, which was processed accordingly. However, later, the Complainant was admitted to the ICU of Max Super Specialty Hospital, where he incurred bills totalling Rs. 5,62,984/-. The Insurance Company dismissed this claim. Feeling aggrieved, the Complainant approached the District Consumer Disputes Redressal Commission – X, New Delhi (“District Commission”) and filed a consumer complaint against the Insurance Company.

In response, the Insurance Company contended that the pre-authorization request for the second treatment was denied, based on the exclusion clause 8.4 of the policy's T&C. The clause stated that expenses related to screening, counselling, and treatment of complications associated with autoimmune disorders fall under 'permanent exclusion'. Additionally, the Insurance Company argued that the claim for medical bills totalling Rs. 5,62,984/- was not submitted by the Complainant.

Observations by the District Commission:

The District Commission noted that the Complainant's medical history revealed a diagnosis of DM Type 2, Hypothyroidism, and Myasthenia Gravis, which significantly impacted his health. Following the initial hospitalization at Neo Hospital, where the Complainant was diagnosed with respiratory infection and Myasthenia Gravis, a cashless claim was successfully processed by the Insurance Company. Despite being discharged against medical advice, the Complainant continued to experience breathing difficulties, leading to readmission to Max Health Care Hospital, where he was diagnosed with Myasthenia Crisis with respiratory failure type 1.

The District Commission held that the Insurance Company approved the initial claim but rejected the subsequent one. It held that this raised questions regarding consistency in the company's actions.

The Insurance Company contended that during the initial hospitalization, the Complainant received treatment for lower respiratory tract infection but not for Myasthenia Gravis, whereas treatment for Myasthenia Gravis was administered during the second hospitalization. However, the District Commission held that the Insurance Company failed to provide adequate clarification regarding the differing treatments despite both hospitals reaching the same final diagnosis. The District Commission held that this inconsistency in treatment and claim processing raised doubts about the Insurance Company's adherence to the terms of the policy.

Therefore, the District Commission held the Insurance Company liable for deficiency in services. Consequently, it was directed to reimburse the Complainant for medical bills totalling Rs. 5,80,984/-, with 9% interest from the date of discharge until realization. Additionally, it was directed to pay Rs. 20,000/- as compensation and Rs. 5,000/- as litigation costs to the Complainant.

Case Title: Hari Mohan vs Max Bupa Health Insurance Co. Ltd.