27-year-old cancer survivor from Mumbai gets insurance after 2 years
A nationalised medical insurance company rejected his insurance his claim for a prosthetic replacement surgery.mumbai Updated: Feb 05, 2018 01:02 IST
A 27-year-old bone cancer survivor from Borivli finally received his insurance cover from a nationalised medical insurance company, two years after it rejected his insurance claim for a prosthetic replacement surgery and withheld the balance amount.
The insurance ombudsman in the city instructed the company in July 2017 to pay the balance of Rs1.22 lakh with interest to the claimant, Narendra Shetty. The last due of the amount was paid in January. HT has a copy of the forum’s observations and verdict.
In May 2005, Shetty was diagnosed with Ewing’s Sarcoma, a type of bone cancer, following which he got a prosthetic implant on his right thigh. A decade later, although he was completely cancer free, his implant wore out. In January 2016, he had a new titanium prosthesis implanted. The surgery and hospitalisation cost him Rs5,90,000. He claimed the amount of his insurance cover within a week of his surgery, but the insurance company rejected it stating that “Ewing’s Sarcoma is a genetic disorder and genetic disorders are not payable.”
Doctors have said that it is common for insurance companies to reject claims on ‘inadmissable grounds.’ Dr Manish Agarwal, orthopaedic oncologist, PD Hinduja Hospital, who operated on Shetty, said, “It looks like they have a standard response ready, to reject claims on the most illogical bases.” Shetty wrote to the company, and attached the doctor’s letter which said “the surgery was conducted because the old implant had worn out and not to treat his cancer.” The letter also clarified that Ewing’s Sarcoma is not genetic.
After two months, the insurance officials agreed but paid only Rs1,50,000 and rejected the rest of the amount. Shetty then wrote to the chief managing director of the company. After the company kept rejecting the claim for over a year, he decided to approach the ombudsman.
In July 2017, the ombudsman forum heard both the parties and ruled in Shetty’s favour. It observed that Shetty was operated because his prosthesis had worn out, which had nothing to do with his cancer. “After a point, it was not really about the money, but a matter of principle,” Shetty said. “If I hadn’t fought now and needed a surgery again years later, they could have rejected the claim on the same grounds and I would not have been able to object it,” he said.