Mumbai: Observing that the ground on which the insurer refused to settle a minor's medical claim was far from medical evidence, the south Mumbai district’s consumer forum ordered Max Bupa Health Insurance to pay the repudiated medical bill amount of Rs 10,68,160. It also directed the firm to pay an additional Rs 80,000 towards the co-complainant’s (parents) mental agony and Rs 20,000 towards the litigation charges.
The case dates back to 2015 when Amalia Akerkar suffered from severe dizziness, vomiting and ultimately fell unconscious at school one day. She was immediately taken to the Breach Candy Hospital, where she was admitted in ICU. Akerkar was diagnosed with embolic stroke (blood vessel blockage) and the presence of patent foramen ovale (PFO), a congenital condition. As per the medical definition, PFO is a hole between the left and right atria (upper chambers) of the heart, which exists in every unborn child, but most often it closes immediately after birth.
The condition was however resolved by a transcatheter closure of PFO, a less invasive procedure than open-heart surgery. The treatment cost the complainant’s father Rs10,68160, which he claimed from the insurer. However, the firm rejected his application, saying that the disorder was a pre-existing one.
The complainant approached the Ombudsman, who upheld the insurer's decision. Finally, the aggrieved approached the forum. It referred to a National commission’s judgment submitted by the complainant, which read, “Most people are totally unaware of the symptoms of the disease that they suffer. Hence, they cannot be made liable to suffer because the insurance company relies on their clause (pre-existing condition) in a mala fide manner to repudiate all the claims.”
The judgment further said that humans are unaware of the pre-existing conditions and everyone realises much later (after diagnosis) that he/she should have known about the ailment before from some symptom. If this is so every person should do medical studies and further not take any insurance policy, it added.
While commenting on the repudiation of the claim by the insurance firm and the Ombudsman, the forum said that the decision was “arbitrary...based on surmises, fantasy and far far away from medical evidence.”
The repudiation of the claim appears to have taken place with oblique motive in avoiding the liability. By the doing so, the authorities have added to the agony and mental torture of the complainant and her parents, held the forum.
