Indore (Madhya Pradesh): The consumer court has directed an insurance company to pay Rs 9,08,163, along with 7% interest from February 15, 2021 and Rs 25,000 for mental agony and a compensation of Rs 5,000 to the complainant within two months.
The complainant Ajay Kumar Jain acquired two medical insurance policies from The New India Insurance Company Limited for the duration of June 22, 2018 to June 21 2019 with a cover of up to Rs 5,00,000 and a top up policy (up to 10,00,000) from June 22, 2019 to June 21, 2022 respectively.
The policy covered the complainant, his wife Suchit Jain and son Sujay Jain and was renewed regularly as per the rules. In 2018, the complainant’s wife was diagnosed with breast cancer after which she was hospitalised on September 24 till 28.
She was hospitalised multiple times after September and the complainant presented the bills for the claim of the policy. However, the insurance company rejected multiple claims not due to undisclosed illnesses or policy lapses but because certain medications administered during the treatment were not listed under chemotherapy coverage in the policy.
The insurance company rejected claims for the injection TRASTUZUMAB 400 MG, arguing that it was not part of chemotherapy as per their policy. However, the complainant provided medical evidence that the injection is widely recognised as essential in treating breast cancer. After which the insurance company stated that the policy complainant has taken is up to 5,00,000 and does not cover other expenses.
Despite the rejection, after further deliberation, some claims were eventually approved, including those under the separate top-up policy. The complainant asserted that the rejection of the claims, based on technicalities, was unjustified and argued that the medical treatments, including chemotherapy and related procedures, were essential and valid under the policy.
While the insurance company presented the statement of a doctor stating that the medication used is not appropriate for cancer treatment. But, later it was discovered that the doctor was not authorised to examine the cancer patients.
