Maharashtra Consumer Panel Orders Apollo Munich To Pay ₹20 Lakh To Mumbai Doctor Over Wrongful Claim Rejection

Mumbai: The Maharashtra State Consumer Disputes Redressal Commission has directed Apollo Munich Health Insurance Company Ltd. to pay Rs 20 lakh, along with 9% interest from May 27, 2017, the date on which the insurance claim was repudiated, to a Mumbai-based doctor. The Commission has also directed the insurer to pay an additional Rs 20,000 as compensation for the complainant’s immense mental agony and Rs 25,000 towards litigation costs.

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The Commission, in its order, held that the insurer’s decision to repudiate the claim on the ground that the complainant had not disclosed his child’s history of delayed speech amounted to an egregious deficiency in service and a ruthless, money-making trade practice designed to defeat genuine consumer claims.

“This Commission observed that the grounds on which the Insurance Company repudiated the Complainant’s initial claim and unilaterally terminated the medical policy are completely arbitrary, legally untenable, and malicious,” the order states.

The complaint was filed by Dr. Amol Ingule, who had purchased an Optima Restore Floater health insurance policy with a sum insured of Rs 20 lakh for his family in February 2017.

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According to the complaint, his elder son was admitted to Apollo Hospital, Navi Mumbai, in April 2017 with severe stomach pain and underwent emergency surgery. When Dr. Ingule sought reimbursement of the medical expenses, the insurer rejected the claim in May 2017, alleging non-disclosure of the child’s history of delayed speech. The doctor maintained that delayed speech was neither a disease nor a permanent medical condition and that his son had overcome it during childhood.

The child’s condition later deteriorated after he was diagnosed with Burkitt’s lymphoma, a form of blood cancer. During the course of treatment, he also developed a fungal brain infection and underwent multiple surgeries at Tata Memorial Hospital and Apollo Hospital. Despite extensive treatment, the child died in February 2018. Dr. Ingule stated that he spent more than Rs 33.58 lakh on his son’s treatment.

The Commission noted that although the insurance company had appeared through counsel, it failed to file its written statement within the prescribed period and also did not submit written arguments despite being granted opportunities. Consequently, the complainant’s evidence remained unchallenged.

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