Mumbai, August 19, 2026: The Suburban Mumbai District Consumer Dispute Redressal Commission (DCDRC) has held Max Bupa health insurance firm guilty of deficiency in providing required services by repudiating the claim.
While pulling up the insurance firm, the commission in its orders maintained that insurance policies must be construed to promote fairness and justice rather than to penalise the insurer.
Waiting Period Disputed
Further, the commission in its orders maintained that a health insurer cannot rely on a 24-month waiting period to repudiate a claim arising from a first-time, life-threatening case, especially of acute pancreatitis in this case when there is no evidence of any pre-existing disease.
The commission directed Max Bupa Health Insurance Co. Ltd. to pay Rs 5 lakh, the sum assured under the policy, along with 6% annual interest from the date of filing of the complaint.
It also awarded Rs 50,000 as compensation for mental agony and harassment and Rs 10,000 towards litigation costs. The order was passed on July 3, 2026.
Hospitalisation And Claim
The complaint was filed by Sujata Sanjay Patole after her husband, Sanjay Patole, died on February 7, 2019, following acute pancreatitis with multiple organ failure.
He was initially admitted to Criticare Hospital, Andheri, on January 31, 2019, after suffering severe stomach pain, vomiting and sweating. His condition deteriorated and he was placed on a ventilator before being shifted to Lilavati Hospital for advanced treatment.
Patole had obtained a Health Companion Variant 2 policy in October 2017 for a sum assured of Rs 5 lakh and subsequently renewed it. The family incurred Rs 1,94,257 at Criticare Hospital and Rs 4,15,594 at Lilavati Hospital, totalling Rs 6,09,851. Although the policy was cashless, the complainant was made to pay the hospital bills after being assured that the expenses would be settled.
Commission Rejects Insurer’s Stand
The insurer subsequently repudiated the claims, relying on certain clauses of the policy, which prescribed a 24-month specific waiting period for pancreatitis and stones in the biliary and urinary system. The insurer argued that the waiting period was part of the policy terms and was in accordance with IRDA guidelines.
Rejecting the insurer’s stand, the commission noted that neither the complainant nor the insurer had alleged that Patole suffered from pancreatitis before obtaining the policy.
The complainant had also produced a certificate from treating doctor Dr Hiren Desai stating that the pancreatitis was a rare case with no apparent cause and that Patole had no symptoms before his hospitalisation. The insurer failed to produce contrary or expert evidence to establish any pre-existing pancreatitis.
The commission observed that the waiting-period clause was intended to address cases where an insured person had a documented medical condition, undergone treatment or had been diagnosed with pancreatitis before or at the time of obtaining the policy. It held that the clause could not be applied to a death claim arising from a non-pre-existing condition.
Repudiation Termed Arbitrary
The commission further held that applying the 24-month waiting period to a first-time, acute and life-threatening case requiring ICU and ventilator treatment was “illegal and arbitrary” and contrary to the purpose of insurance norms. It termed the insurer’s repudiation “hyper-technical” and held that the company had committed deficiency in service.
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The commission also took exception to the insurer’s conduct in making the complainant pay the hospital bills under the assurance that the cashless claim would be settled and subsequently repudiating the claim. It held this amounted to an unfair trade practice.
Accordingly, the complaint was partly allowed and the insurer was directed to make the payments within 60 days of receiving the order.
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