In a landmark ruling, a Mumbai consumer forum directed Max Bupa Health Insurance to settle a ₹5 lakh medical claim for pancreatitis, overturning the insurer’s rejection citing a 24-month waiting period.
Background
The policyholder had filed a claim under a health insurance policy after being diagnosed with pancreatitis. The insurer rejected the claim on grounds that pancreatitis falls under a 24-month waiting period, a common provision in health policies that defers coverage for pre-existing conditions.
Forum’s rationale
According to the order, the consumer forum held that the insurer must honor the claim because the hospitalization occurred within the policy term and the waiting period clause could not be used to deny coverage in this case. The decision underscores the forum’s stance on protecting consumer rights while upholding policy terms.
Implications for policyholders
- Signals that waiting-period exclusions may be scrutinized by consumer forums when relief is warranted
- Could push insurers to settle claims promptly to reduce complaints
- Reminder for policyholders to track coverage terms, pre-existing conditions, and claim timelines
Industry watchers say the ruling may influence similar cases in Maharashtra and beyond, prompting insurers to revisit their interpretation of waiting periods and the documentation required for pancreatitis claims.
