Cancer Patient Wins Insurance Claim Battle Against New India Assurance 💉⚖️

 

Brief Case Facts 🏥📜

In a case that highlights the struggles of patients with life-threatening illnesses, the National Consumer Disputes Redressal Commission (NCDRC) ruled in favor of Vishal Dhupar, a Stage IV Neuroendocrine Cancer patient, in his dispute with New India Assurance Co. Ltd. Mr. Dhupar sought reimbursement of ₹1,02,867 under a health insurance policy for chemotherapy treatment using the drug Sandostatin LAR. However, his claim was denied, prompting him to appeal to the consumer court. The Haryana State Consumer Commission dismissed his complaint, which led him to approach the NCDRC.

Contentions of the Appellant (Vishal Dhupar) 💪📑

Mr. Dhupar argued that Sandostatin LAR was prescribed by his oncologist at the Rajiv Gandhi Cancer Institute, a premier cancer treatment center, as part of a chemotherapy regimen to treat his advanced cancer. The prescription clarified that the drug was not a growth hormone but a receptor blocker aimed at slowing the spread of cancer cells. He contended that his treatment met the policy’s terms, which allowed reimbursement for medically necessary procedures, including day-care treatments that did not require overnight hospitalization.

To support his claim, he cited judicial precedents emphasizing that insurance policies should be interpreted in favor of policyholders, especially when ambiguities arise. He also pointed out the lack of any policy clause specifically excluding his treatment.

Contentions of the Insurer (New India Assurance) 🚫📋

New India Assurance argued that the claim was ineligible because the policy required a minimum 24-hour hospitalization for reimbursement unless the procedure was explicitly listed as a day-care treatment, which Sandostatin LAR was not. The company maintained that the drug was not chemotherapy but a hormone treatment aimed at slowing malignant cell growth. As a result, the insurer denied the claim, stating it was not covered under the policy’s terms.

The insurer also justified its denial on the grounds that standard chemotherapy drugs or procedures, apart from Sandostatin, were not prescribed to the patient.

Key Observations by the NCDRC 🔍⚖️

The NCDRC noted several critical points in its detailed judgment:

1. Medical Necessity: The commission observed that Mr. Dhupar’s medical records from the Rajiv Gandhi Cancer Institute explicitly described Sandostatin LAR as part of his chemotherapy regimen, contradicting the insurer’s claim that it was a growth hormone. The insurer failed to present expert evidence supporting its interpretation.

2. Policy Interpretation: The NCDRC emphasized that health insurance policies must be interpreted in a consumer-friendly manner. The policy clearly stated that medically necessary treatments, even those requiring partial hospitalization, were eligible for reimbursement. The rejection of Mr. Dhupar’s claim was deemed unjustifiable under these terms.

3. State Commission’s Errors: The NCDRC criticized the Haryana State Consumer Commission for procedural errors. While dismissing the complaint on jurisdictional grounds, it went on to adjudicate the merits of the case, which was inappropriate.

Final Judgment and Conclusion 🎉💵

The NCDRC allowed Mr. Dhupar’s appeal and set aside the State Commission’s dismissal of the complaint. It directed New India Assurance to:

1. Reimburse ₹1,02,867 with 9% annual interest from the date of the complaint. If delayed beyond four weeks, the interest rate would increase to 12%.
2. Pay ₹25,000 as litigation costs.
3. Expedite the processing of any future claims under the policy, including pre- and post-hospitalization expenses.

This ruling brings relief to Mr. Dhupar, not just financially but also emotionally, as he continues his battle against cancer. The decision reinforces the accountability of insurers and the rights of policyholders to fair and transparent treatment. 🌟💪

Disclaimer : This article summarizes the judgment by the National Consumer Disputes Redressal Commission (NCDRC) in First Appeal No. 555 of 2023 (Vishal Dhupar vs. New India Assurance Co. Ltd.) for informational purposes only. It is not intended as legal advice. Readers are advised to consult legal professionals for specific guidance. The content reflects the details of the case as outlined in the judgment and should not be relied upon as a substitute for professional counsel or the full text of the decision.

Image Disclaimer : The accompanying image used in this article is generated using artificial intelligence (AI) and does not depict any real persons, places, or events related to the case discussed. It is purely for illustrative purposes and should not be construed as an accurate representation of the individuals or circumstances involved.