Insurer to cough up ₹5 lakh for denying man’s medical claim

The insurance company maintained that the claim of ₹10,88,354 was denied as it was more than the limit allowed under the policy

The District Consumer Disputes Redressal Commission has directed an insurance company to pay ₹5 lakh, along with interest, to a local resident whose medical claim was denied.

Along with ₹5 lakh, the insurance company has been directed to pay interest at 6% per annum. (Getty Images/iStock photo)

Filing a case against Max Bupa Health Insurance Company Limited, Lalit Kumar, a resident of Khuda Lahora, had stated that he opted for a cashless plan with a re-fill feature, namely “Health Companion Variant 2” for himself, his wife and their child on December 30, 2017, and got it renewed till December 2021. The policy was for ₹5 lakh, with re-fill benefit of the same amount.

In May 2020, their son Kartik, 13, underwent a major surgery at Paras Bliss Hospital for a malignant tumour. His complete treatment at two hospitals entailed an expenditure of ₹9 lakh. In October, he was diagnosed with Covid-related pneumonia with fungal and bacterial infections, leading to medical expenses worth ₹16 lakh.

Lalit said the insurance company was timely informed about the medical claims, but these were denied, citing “terms and conditions of the policy”.

The insurance company maintained that the claim of ₹10,88,354 was denied as it was more than the limit allowed under the policy.

Hearing both sides, the consumer commission directed the firm to pay to the complainant ₹5 lakh, along with interest at 6% per annum, from the date of rejection of the claim, February 9, 2021, till the date of payment.