‘A person is dying and you want to file a reply?’ Delhi HC slams insurance firm for denying claim to cancer patient

Justice Sachin Datta slammed the insurance company orally, saying, “A person is dying and you want time to file a reply? Ask the (managing) director to be in court next time.”

The court sought a response from the insurance company as well as the insurance regulatory body. Keeping in mind the urgency, it posted the matter for consideration on May 14. It also directed the insurance company’s managing director, Atul Gulati, to remain present before the court on the next date.

Pandey, the sole breadwinner of his family, moved the HC on April 21 with a petition against the Insurance Regulatory and Development Authority of India (IRDAI) and his medical insurance company, Care Health Insurance Limited, for the “illegal, arbitrary rejection” of his valid health insurance claim by Care.

He said he complained about the rejection to IRDAI, which “failed to carry out its statutory duty”.

A resident of Bihar, be was diagnosed with Stage 3 oral/mouth cancer which has affected his mouth, food pipe and wind pipe. He has been suggested a tracheostomy surgery and 35 cycles of chemotherapy. Each cycle comprises two rounds and a booster dose, of which he has only completed four.

Speaking to The Indian Express, his 23-year-old daughter, Shriyanshi, said: “He was 92 kg and within a month, his weight dropped to 56. He has to be admitted on May 6 for immunotherapy treatment. He is scheduled for 200 mg of the medicine; and 100 mg costs Rs 1.90 lakh. He is already on a semi-solid/liquid diet.”

Pandey, who has had health insurance since 2014, was earlier insured by another private company. He got it ported to Care, purchased a plan worth Rs 15 lakh, and continued to regularly pay premiums.

Shriyanshi said, “He switched because he thought there were better benefits (at Care). This was his first insurance claim. We uploaded all requisite documents, but they kept raising queries. It took more than a week for them to communicate their decision — that they had rejected it… we know he has never consumed alcohol or tobacco or any such substance. We made over 200 calls, and all they kept saying was ‘call us during working hours’. When I called during working hours, they either would not respond and would say ‘we’re processing’… We have already spent around Rs 20 lakh by now. We would earlier tell him there is no point in taking insurance, and see how it’s playing out now.”

“I was preparing for UPSC exams, but now I don’t know what to do. I’m running around hospitals while my mother is taking care of my father’s daily needs,” she added.

Pandey told the court that “… his life span would be drastically reduced to maybe around 3-4 months” if he does not receive immediate treatment.

“The treatment is very expensive and can be covered by the petitioner’s insurance policy. But the petitioner can’t pay… out of his own pocket as he is employed as a Sr. Assistant with an employee’s cooperative society and all his savings have been used for educating his daughter,” the court was told.

His insurance company had rejected his claim, stating “discrepancy in medical documents – “personal habit of tobacco” — due to which he was forced to get himself discharged from the hospital, having exhausted his financial savings after clearing hospital expenses, the plea said.

Pandey pointed out that the hospital in January had confirmed, following tests, that his lungs were fine.

He also said the rejection “has left him in life-threatening situation, which would not have arisen if appropriate rules, guidelines, etc. had been issued by (IRDAI) regulating cashless insurance facility.”

Pandey is now seeking the court’s direction to the IRDAI to issue comprehensive directions, guidelines, etc, to streamline the process of clearance of cashless medical facilities.

He is also seeking that his claim denial be set aside and that the insurance claim of Rs 20,81,000 incurred by him so far be honoured. In addition, he sought that he be paid Rs 10 lakh as compensation for the mental agony and harassment he had to undergo.