Insurance firm asked to pay full claim to heart patient

Jitendra Nanalal Rupani had a mediclaim policy from the National Insurance. On August 16, 2013, Rupani developed acute breathlessness. He was taken to Kohinoor Hospital in Kurla, where an angiography was performed followed by a coronary bypass surgery on August 19. The hospital bill came to 5,25,089. Rupani's policy was for Rs3 lakhs with a cumulative bonus of 1.5 lakh, hence he lodged a claim for reimbursement of Rs4.5 lakh.Yet, the insurer sanctioned only 3,70,800.
Rupani filed a complaint before the South Mumbai District Forum which ordered the insurance company to pay the balance 79,200 with 9% interest from December 23, 2013 till date of payment. In addition, compensation of 5,000 and litigation costs of 5,000 were also awarded.
National Insurance challenged this order before the Maharashtra State Commission. It argued the deduction of 79,200 was due to capping of limits under the policy. The insurer contended Rupani had accepted this amount in full and final settlement without protest, so the complaint was not maintainable.
Rupani's lawyer, Binoy Gupta, argued the policy was taken in 2004, while capping was introduced in 2007, so it would not apply to existing policy holders. The insurer was unable to show the change in the policy terms had been communicated and that Rupani had consented to the revised policy conditions.
Relying on the Supreme Court's interpretation in Biman Krishna Bose v/s United India Insurance, the State Commission concurred with Binoy Gupta's submission, and held the insurance company was not entitled to unilaterally make any changes at the time of renewal of the policy. It held a renewed policy would have to be on identical terms and conditions as those governing the original contract of insurance.
By its order of March 20, 2019 delivered by A K Zade for the Bench presided over by justice A P Bhangale, the Maharashtra State Commission concluded that capping could not be made retrospectively applicable to old policies. It dismissed the appeal and upheld the Forum's order directing National Insurance to pay the balance 79,200 along with interest, compensation and costs.
(The author is a consumer activist and has won the Govt. of India's National Youth Award for Consumer Protection. His email is jehangir.gai.columnist@