Consumer Court Orders Max Bupa to Pay Rs 5 Lakh Over Denied Andheri Hospital Claim
The Suburban Mumbai District Consumer Dispute Redressal Commission has held Max Bupa Health Insurance Co. Ltd. guilty of deficiency in service for arbitrarily repudiating an insurance claim following the death of a patient who was initially treated at Criticare Hospital in Andheri.
The commission ordered the insurance company to pay the sum assured of Rs 5 lakh along with 6% annual interest from the date the complaint was filed. The firm was also directed to pay Rs 50,000 as compensation for mental agony and harassment, alongside Rs 10,000 towards litigation expenses. The order was passed on July 3, 2026.
The case arose from a complaint filed by Sujata Sanjay Patole after her husband, Sanjay Patole, passed away on February 7, 2019, due to acute pancreatitis with multiple organ failure. He had been admitted to Criticare Hospital in Andheri on January 31, 2019, suffering from severe stomach pain, vomiting, and sweating. As his condition worsened, he was put on ventilator support and subsequently shifted to Lilavati Hospital for advanced medical care.
Patole had purchased a Health Companion Variant 2 policy with a sum assured of Rs 5 lakh in October 2017 and later renewed it. The family incurred medical expenses of Rs 1,94,257 at Criticare Hospital and Rs 4,15,594 at Lilavati Hospital, amounting to a total of Rs 6,09,851. Even though the policy provided cashless coverage, the family was compelled to pay the hospital bills directly under the assurance that the expenses would be settled later.
Max Bupa subsequently rejected the claim, citing a policy clause that stipulated a 24-month waiting period for pancreatitis and stones in the biliary and urinary systems. The insurer maintained that this condition conformed to Insurance Regulatory and Development Authority guidelines.
The consumer commission dismissed the insurer's arguments, observing that neither party alleged Patole had pancreatitis prior to taking the policy. A certificate from treating physician Dr Hiren Desai confirmed that the pancreatitis was a rare case with no apparent cause and that Patole had shown no previous symptoms. The insurer failed to submit contrary expert evidence.
The commission ruled that invoking a 24-month waiting period for a first-time, life-threatening emergency was illegal, arbitrary, and hyper-technical, amounting to an unfair trade practice. The insurer was directed to complete the payments within 60 days of receiving the order.
