Insurance company to pay Rs 5.5 lakh for poor service

Chennai: The District Consumer Disputes Redressal Forum, Chennai (North), has directed an insurance firm to pay Rs 5.55 lakh to a hockey player who had undergone treatment.

In the petition Dr J. Ramprasad, (26) Purasawalkam, submitted that he was an athlete and a hockey player. He obtained a health insurance policy from Max Bupa Health Insurance Co. Ltd., Aminjikarai, in January 2011.

He insured for a sum of Rs 5 lakh for ‘Heartbeat Gold’ policy and paid a premium of Rs 6,813. In May 2011, he had a breathing problem and took a chest x-ray at a scan centre, which showed a lesion on his right chest. He was admitted to the Rajiv Gandhi Institute of Tuberculosis and Chest Diseases, Bengaluru on December 21, 2011.

Later, he was referred to the National Institute of Mental Health and Neurological Sciences (NIMHANS), Bengaluru. A radiologist suggested him to undergo Angiographic Coil Embolisation for Pulmonary Arteriovenous Malformation (PAVM). He incurred an expenditure of Rs 6,26,844 for the treatment.

On December 30, 2011, he sent a letter to Max Bupa Health Insurance Co.Ltd, New Delhi and its branch in Aminjikarai, claiming a sum of Rs 6,26,844.

However, the insurance firm rejected his claim on the ground that the ailment falls under permanent exclusion category. In the petition, he sought direction to the insurance firm to pay a compensation of '8 lakh including the amount spent for treatment.

In its reply, the Max Bupa Health Insurance stated that the policy specifically excludes from coverage, expenses for treatment arising out of any congenital condition. He has undergone treatment was for PAVM which was a rare pulmonary vascular anomaly and invariably congenital.

His claim was submitted on December 31, 2011, but no information or document was furnished when the treatment was planned and kept the Opposite firm in the dark during those times.

The firm has not committed any deficiency in service and hence the firm sought to dismiss the complaint with cost. The bench comprising K. Jayabalan and member T. Kalaiyarasi, said the congenital conditions mean a disease which exists right from the birth of the child. He was not having congenital disease right from his birth and he had acquired ailment - PAVM, only after his birth.

Since it is decided that he was not having a congenital disease, the claim made by him was repudiated by firm amounts to deficiency in service on their part. Hence, the bench directed the firm to pay him a compensation of '5.55 lakh in six weeks.