Pay for juvenile diabetes treatment: Court

Pay for juvenile diabetes treatment: Court

INSURERS COULD NOT ESTABLISH THAT CHILD’S TYPE-1 DIABETES IS GENETIC DISORDER

TIMES NEWS NETWORK

Ahmedabad: 10.12.2021

A consumer court has ordered an insurance companies to reimburse the expenditure on treatment of juvenile diabetes with observation that the insurers could not establish that the child’s type-1 diabetes falls under the category of genetic disorder.

According to case details, Viramgam-resident Anilkumar Chavda’s 10-year-old son suffers from type-1 diabetes and was hospitalized in 2017.

Chavda had obtained a Happy Family Floater Policy with Silver Plan from the Oriental Insurance Co Ltd and M D India Health Care Services Pvt Ltd.

He sought reimbursement for treatment, Rs 48,882, which the insurers declined on the ground that the patient was treated for a disease which is a genetic disorder and according to the Mediclaim policy clause 4.15, such claim is not payable.

Chavda sued the insurers through Mukesh Parikh of Grahak Suraksha and Action Committee with the Consumer Dispute Redressal Commission, Ahmedabad (City), where the insurance companies submitted that the claim papers were scrutinised and investigated by TPA and it found that the treatment for the child was genetic in origin and therefore not payable.

After hearing the case, the commission said that the child was hospitalised for type-1 diabetes treatment, but there was nothing in medical papers to indicate that the ailment falls under the category of genetic disorder, nor was there a remotest whisper in any of the papers produced by the insurers.

The commission cited a 2018 circular issued by the Insurance Regulatory and Development Authority of India (IRDAI) and how the circular was put in abeyance after the orders of the Supreme Court and Delhi high court with regard to rejection of Mediclaim related to treatment of genetic disorder. Since the insurers in this case could not adduce any rebuttal evidence to establish that type-1 diabetes is a genetic disorder, “we hold that the opponents (insurers) have wrongly rejected the claim and which is a pointer to the deficiency in service and unfair trade practice”.

The commission ordered the insurers to pay Rs 43,938 with 7% interest since the date of filing of complaint. It deducted 10% of the claim according to the policy only. Besides, the insurers have been told to pay Rs 5,000 to Chavda as compensation towards mental harassment and legal expenditure.