20 hrs ago
Mumbai Forum Orders Insurer To Pay Rejected Pancreatitis Claim
A man had health insurance when he suddenly became seriously ill with pancreatitis.
His policy included a waiting period for some illnesses, including pancreatitis.
The insurer refused to pay because the illness happened within 24 months of the policy starting.
The man’s family said there was no proof that he had pancreatitis before buying the policy.
The consumer commission agreed that the insurer had not shown the disease was pre-existing.
A doctor had described the illness as rare and having no apparent cause.
The family had paid about ₹6.10 lakh in hospital bills after borrowing money.
The commission ordered the insurer to pay the claim.
It also questioned why cashless treatment was not provided despite being included in the policy.
The Mumbai Suburban District Consumer Disputes Redressal Commission directed Max Bupa, now Niva Bupa, to pay a rejected pancreatitis claim.
The policyholder had ₹5 lakh of cover under a Health Companion Variant 2 policy purchased in October 2017.
He developed acute pancreatitis in January 2019 and died on February 7, 2019, after multiple organ failure.
The insurer rejected two claims by citing a 24-month waiting period for pancreatitis under Clause 5.3.
The commission said the insurer had not proved that the illness was pre-existing and called the repudiation a deficiency in service and unfair trade practice.
- Who
- The deceased policyholder’s wife, Max Bupa Health Insurance Co. Ltd., now Niva Bupa Health Insurance Co. Ltd., and the Mumbai Suburban District Consumer Disputes Redressal Commission.
- What
- The commission ordered the insurer to honor a rejected pancreatitis claim and found the rejection to be a deficiency in service and unfair trade practice.
- Where
- The case was decided by the Mumbai Suburban District Consumer Disputes Redressal Commission; treatment took place at Criticare Hospital and Lilavati Hospital.
- When
- The policy began in October 2017, pancreatitis developed in January 2019, the policyholder died on February 7, 2019, and the commission later issued its ruling.
- Why
- The insurer relied on a 24-month waiting-period clause, but the commission found that it had not proved the pancreatitis was pre-existing.
Policyholder’s Position
Insurer’s Position
Whether the waiting period applied
Policyholder’s Position
The family argued that the clause could not automatically exclude the claim because the insurer had not shown that pancreatitis existed before the policy began.
Insurer’s Position
The insurer argued that the claim was excluded because pancreatitis developed before the 24-month waiting period ended.
Nature of the illness
Policyholder’s Position
The commission noted the treating doctor’s view that the pancreatitis was rare and had no apparent cause, supporting the family’s position that it arose unexpectedly.
Insurer’s Position
The insurer relied on the policy’s specific waiting-period provision rather than establishing, according to the commission, that the illness was pre-existing.
Cashless treatment
Policyholder’s Position
The family said it had to borrow money and pay approximately ₹6.10 lakh despite the policy offering cashless treatment.
Insurer’s Position
The insurer later repudiated the claim after the family paid the bills, relying on the waiting-period clause.
Key facts
- Policyholder’s cover
- ₹5 lakh under Max Bupa’s Health Companion Variant 2 policy
- Policy start
- October 2017
- Illness
- Acute pancreatitis with multiple organ failure
- Hospital expenses
- Approximately ₹6.10 lakh: ₹1.94 lakh at Criticare Hospital and ₹4.15 lakh at Lilavati Hospital
- Insurer’s reason for rejection
- Clause 5.3, which imposed a 24-month specific waiting period for pancreatitis
- Commission’s finding
- The insurer failed to establish that pancreatitis was pre-existing
- Cashless treatment issue
- The policy provided cashless treatment, but the family paid the hospital bills themselves
Sources
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