Mumbai Commission Orders Max Bupa to Pay ₹5 Lakh

The Suburban Mumbai District Consumer Dispute Redressal Commission has held Max Bupa health insurance firm guilty of deficiency in providing required services by repudiating a claim. The commission ordered Max Bupa to pay ₹5 lakh, the sum assured under the policy, along with 6% annual interest from the date of filing of the complaint.

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.

Patole had obtained a Health Companion Variant 2 policy in October 2017 for a sum assured of ₹5 lakh and subsequently renewed it. The family incurred ₹1,94,257 at Criticare Hospital and ₹4,15,594 at Lilavati Hospital, totalling ₹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.

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 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 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.

The commission directed Max Bupa Health Insurance Co. Ltd. to pay ₹5 lakh, the sum assured under the policy, along with 6% annual interest from the date of filing of the complaint. It also awarded ₹50,000 as compensation for mental agony and harassment and ₹10,000 towards litigation costs. The order was passed on July 3, 2026.

This judgment is significant as it sets a precedent for insurance companies to not rely solely on waiting periods to repudiate claims. It also highlights the importance of insurance companies to act in good faith and not to penalize policyholders unfairly.

The commission's decision is a victory for the policyholder and a reminder to insurance companies to prioritize fairness and justice in their dealings with customers. The order is a significant development in the insurance sector and is likely to have implications for policyholders and insurance companies alike.

In conclusion, the Mumbai Commission's order is a landmark judgment that emphasizes the importance of fairness and justice in the insurance sector. It is a reminder to insurance companies to act in good faith and to prioritize the interests of policyholders. The judgment is a significant development in the insurance sector and is likely to have far-reaching implications for policyholders and insurance companies alike.