A Mumbai consumer commission has mandated Max Bupa to pay Rs 5 lakh to a family after ruling that the insurer’s rigid interpretation of policy terms unjustly denied a claim following the death from acute pancreatitis, highlighting growing judicial scrutiny of health insurance disputes.
A Mumbai consumer commission has ordered Max Bupa Health Insurance to pay Rs 5 lakh to the family of a policyholder whose claim was rejected after his death from acute pancreatitis, saying the insurer had taken an overly rigid view of the policy terms. The Suburban Mumbai District Consumer Dispute Redressal Commission said insurance contracts must be read in a way that promotes fairness, not to defeat a valid claim through technicalities.
The case arose after Sanjay Patole was admitted to hospital on January 31, 2019, with severe stomach pain, vomiting and sweating, and later died on February 7 that year after multiple organ failure. His wife, Sujata Sanjay Patole, told the commission that the family had bought a Health Companion Variant 2 policy in October 2017 with a sum insured of Rs 5 lakh and had renewed it. The commission said the insurer had relied on a 24-month waiting period for pancreatitis, but there was no evidence that Patole had the disease before taking the cover.
In rejecting the insurer’s defence, the commission said the waiting-period clause was meant for cases in which a medical condition already existed, had been diagnosed or had been treated before the policy was bought. It noted that the complainant produced a doctor’s certificate saying the pancreatitis was rare and had no apparent cause, while the insurer did not submit contrary medical evidence. Along with the Rs 5 lakh sum insured, the commission ordered 6% annual interest from the date the complaint was filed, plus Rs 50,000 for mental agony and Rs 10,000 in costs.
Consumer forums elsewhere have recently taken a similar approach. A Delhi commission ruled that an insurer cannot reject a claim simply by saying hospitalisation was not medically necessary unless it has proper medical support for that view, while a Chandigarh commission held that Max Bupa had wrongfully rejected a maternity claim and could not rely on an unrelated medical condition to avoid payment. Separately, in Australia, a federal court ordered Bupa HI Pty Ltd to pay A$35 million in penalties after finding it had made misleading representations to members and providers about health insurance entitlements, underscoring wider scrutiny of the group’s conduct.
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