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Consumer forum pulls up medical insurance firm

Orders the firm to pay bills worth Rs 69,538 raised by complainant and pay Rs 50,000 as compensation.

By: Express News Service | Pune | Updated: January 2, 2016 12:24:02 am

PUNE District Consumer Grievance Redressal Forum (PDCGRF) pulled up an insurance firm and asked it to pay a compensation of Rs 50,000 to a consumer after the firm refused to pay for medical expenses of his wife when she fell ill during her pregnancy period.

While the firm maintained that it was not liable to pay for pregnancy expenses, the customer argued that the ailments were ‘unrelated to pregnancy’. The insurance firm, Max Bupa Health Insurance, had also refused to pay the expenses of childbirth as they maintained that maternity benefits will commence only from the third year. They argued that the delivery happened in the 29 month of the policy and so the child was conceived within 24 months period which is exempt from pregnancy coverage.

The forum trashed this arguments by the insurance firm and observed that it’s a matter of freedom of choice for married couples to decide when they want to have kids and insurance firms can’t put conditions on them in this regard.

Bharat Ballal, a professor of microbiology and resident of Narhe, had moved the forum after the insurance firm refused his reimbursement request.

As per his complaint, he had bought a ‘Heartbeat Individual’ policy from the insurance firm in August 2011 which also covered his wife. In July 2013, when his wife was 17 weeks into her pregnancy she started to have stomach ache. The doctor diagnosed her with ‘hepatic dysfunction’ leading to Hepatitis A. A total cost of Rs 29,538 was issued to Ballal. Similarly, in January 2014, the wife was hospitalised for childbirth and a total of Rs 53,165 were spent on medical care.
When Ballal submitted these bills to the insurance firm for reimbursement, they refused by arguing that when his wife suffered from Hepatitis A she was already pregnant and hence, the expenditure fell under the exemption. It also trashed the childbirth expenses citing the ‘rule’ that childbirth expenses will only be borne after two years of customer into the policy. “They argued that since the child was conceived before the period of 24 months, the delivery expenses which actually happened in 29th month couldn’t be paid. Their refusal to pay the medical expenses for Hepatitis A during the pregnancy period prompts the question ‘Doesn’t a woman have the right to fall ill during the nine months of pregnancy?,” said Ballal.

The forum trashed the arguments by the insurance firm and asked it to pay the bills worth Rs 69,538 raised by Ballal and also pay Rs 50,000 as compensation.“It’s a matter of individual liberty to decide by a couple when they want to have kids. Insurance firms can’t put conditions,” observed the bench headed by V P Utpat, President of PDCGRF.

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