Pvt insurer cites 48-month waiting to reject surgery claim; ordered to pay man Rs 1.98 lakh
The policyholder challenged the decision, arguing that the rejection was unjustified. He approached the consumer commission on August 14, 2024, seeking reimbursement and compensation.
A Delhi consumer commission has directed a private health insurer to pay Rs 1.98 lakh to a policyholder whose claim for sleep apnoea surgery was rejected on the grounds that the condition fell under a 48-month waiting period for pre-existing diseases, The Indian Express reported. The commission found that the insurer had failed to produce medical evidence establishing that the man suffered from the condition before purchasing the policy.
The District Consumer Disputes Redressal Commission, South II, New Delhi, comprising president Monika Aggarwal Srivastava and members Dr Rajender Dhar and Ritu Garodia, held the insurer guilty of deficiency in service and unfair trade practice in an order dated September 30. According to The Indian Express, the commission directed the insurer to reimburse Rs 1,73,010 towards medical expenses, along with 7% annual interest from the date of hospitalisation until payment.
It also awarded Rs 20,000 as compensation for mental agony and harassment and Rs 5,000 towards litigation costs, taking the total award to Rs 1,98,010, excluding interest. "While settling the claims, the insurance company should not be too technical," the commission observed while directing the insurer to pay the amount. The man had sought Rs 1.73 lakh towards medical expenses, Rs 20,603 for pre- and post-hospitalisation costs, interest, compensation and litigation expenses after the insurer declined to settle the claim.
According to the complaint, he began experiencing shortness of breath, nasal blockage and gasping during sleep in March 2022. He consulted a pulmonologist on March 28 that year and was diagnosed with obstructive sleep apnoea. A sleep study subsequently confirmed a severe form of the condition. Doctors advised him to use Auto CPAP therapy, along with medication and nasal sprays. He continued treatment at a private hospital in Faridabad from March 28, 2022, to April 12, 2023.
Although his symptoms improved temporarily for around five months, they later returned. He then consulted ear, nose and throat specialists at another private hospital in New Delhi, where he received treatment between October 2023 and March 2024. When conservative treatment failed to provide lasting relief, doctors advised uvulopalatopharyngoplasty, functional endoscopic sinus surgery and bilateral submucosal diathermy under general anaesthesia.
The surgery was scheduled for April 10, 2024. The hospital sought cashless authorisation from the insurer, which appointed an investigator to collect medical records. The request was not approved, forcing the man to pay Rs 1,73,010 for the procedure himself. Why the insurer cited a 48-month waiting period The insurer told the commission that the man was covered under a family health insurance policy that also included his spouse and daughter, with a sum insured of Rs 1 crore.
It maintained that its investigation indicated he had been using CPAP therapy since 2021 and had also been suffering from depression since that year. The insurer said it sought treatment records through letters dated April 9, April 12 and April 15, 2024. Claiming that the required documents had not been provided, the insurer rejected the cashless request on April 15. It subsequently declined the reimbursement claim on May 4, 2024, invoking the policy's 48-month waiting period for pre-existing diseases and their direct complications.
The policyholder challenged the decision, arguing that the rejection was unjustified. He approached the consumer commission on August 14, 2024, seeking reimbursement and compensation. It noted that the policy had commenced on June 4, 2021, while hospital records referred to the man having experienced nasal blockage for approximately two years at the time of admission. However, the insurer had not produced a medical document, prescription or hospital record establishing that the man suffered from obstructive sleep apnoea before June 2021, when the policy began.
The commission also found a discrepancy in the insurer's reliance on a statement allegedly made by the complainanth's father. The absence of supporting medical evidence weakened the insurer's justification for treating the condition as pre-existing and applying the waiting-period exclusion. Holding the insurer guilty of deficiency in service and unfair trade practice, the commission directed it to reimburse the surgical expenses with interest and pay additional compensation and litigation costs.
Takeaway Policyholders should retain medical records, prescriptions, diagnostic reports, hospital bills and claim-rejection letters. If an insurer relies on a waiting period, consumers can challenge the decision before the appropriate consumer commission when they believe the exclusion has been applied without adequate supporting evidence.
