Mediclaim rejected on ground of “polyps”: Doctor says polyps not cause of illness, Forum penalises Max Bupa to pay 45k

Contention of the insurance company negated and falsified in view of the deposition made by the treating doctor

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Panchkula

6 February 2019

The Panchkula District Consumer Forum today held Max Bupa Health Insurance guilty of wrongly denying a child’s Mediclaim and directed them to pay the claim of Rs.29,114/- to the complainant along with interest @ 9% per annum from 22.12.2017 till realization. A penalty of Rs.15,000/- was also imposed on the company as the repudiation of claim was held to be incorrect, improper and not justifiable.

Jogendra Sharma of Sector 7 Panchkula, in his complaint filed through Pankaj Chandgothia Advocate, said that took a Max Bupa Health Companion Policy for himself, his wife and two children covering the risk to the tune of Rs.3 lacs. During the Policy Period, the complainant’s minor son Tarun Sharma suffered from abdomen pain, vomiting, fever and headache upon which he was got taken to Dhawan Hospital. The child was admitted in the hospital on 2.10.2017 and discharged on 05.10.2017. The claim form was submitted for a total claim of Rs.29,114/-.

Chandgothia contended that the company wrongly rejected the claim on the ground that ailment of the complainant was due to “polyps” which condition was not covered under the Policy. Even, the discharge summary has no such narration or cause of illness. There is no mention of “polyps” in the prescription slip also. Chandgothia said that the treating doctor is the best person to specify the cause of ailment and an outsider cannot over-ride his diagnosis.

The company, in its reply, stated that it has acted strictly as per the policy terms and conditions and have acted within the four corners of the statutory provisions. As per the investigation of the company it was found that the complainant’s son Tarun Sharma had been diagnosed of Gastroenteritis due to multiple GB polyps and had undergone treatment for the same. The said treatment is not covered under the policy as per the policy terms and conditions of the insurance policy.

The Forum President Sh. Satpal in his order held that the prescription slip and discharge summary do not contain any remarks about the presence of gallbladder polyps. “We find no merit and substance in the version of insurance company while rejecting the genuine claim of the complainant. The contention of the insurance company has been found further negated and falsified in view of the deposition made by the treating doctor Dr. Rakesh Jaswal, Medical Superintendent, Dhawan Hospital who has categorically deposed as under:-

That the multiple Gall Bladder Polyps diagnosed on ultrasound abdomen was an accidental finding.

That the Gall Bladder Polyps do not cause Gastroenteritis, hence the polyps had no role in the cause and management of the patient.

That Gall Bladder Polyps as per the studies available in the medical books can be considered as per-cancerous but not cause for gastroenteritis.

That nowhere in the Indoor Case history the Gall Bladder polyps were mentioned as cause of the ailment.”

Thus, we attribute lapse and deficiency on the part of the Insurance company in wrongly declining the genuine claim of the complainant.

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