Stem cell transplant: Insurance company told to reimburse Rs 4 lakh to liver cirrhosis patient

Surat: The consumer commission in Valsad has ordered an insurance company to pay a Rs four lakh claim for stem cell therapy administered to a liver cirrhosis patient, stating that it was a life-saving treatment.The company rejected the claim citing the policy clause, which did not cover stem cell therapy except in certain conditions. However, the Valsad Consumer Disputes Redressal Commission (CDRC) ruled that the insurer misinterpreted the clause to avoid payment.According to details, the Valsad resident was employed as a mutual fund advisor at a private asset management company. He purchased a group health insurance policy covering him and his family for a sum of Rs four lakh for a year starting September 7, 2022.The policyholder was admitted to a private hospital in Ahmedabad for stem cell treatment on May 19, 2023, and underwent a stem cell transplant for liver cirrhosis. On August 18, 2023, the company rejected the claim under clause 28, which states that stem cell therapy surgery is allowed only in haemopoietic stem cells for bone marrow transplant in haematological conditions.The policyholder approached the consumer commission on November 20, 2023. During the hearing, the company's advocate argued that the exclusion clause clearly stated that such treatment claims were ineligible under the policy terms, and the application should be rejected.Conversely, the complainant's advocate contended that the insurer misinterpreted the clause in rejecting the claim. The complainant received treatment as an indoor patient as directed by the doctor, and the letter regarding the treatment was submitted to the insurance company on September 13, 2023. The letter stated: ‘Diabetes and liver cirrhosis were treated with stem cell therapy for his serious health condition, and diabetic condition occurred after corona... Reports indicate liver cirrhosis." However, the company did not accept the letter.After considering the arguments and documents, the commission observed: "The specific exclusions (28) mention – treatment for alopecia, baldness, wigs or toupees and all related treatments." However, the transplant was done to save his life, the commission noted.The forum also noted that the insurance firm failed to provide any expert opinion on the complainant's treatment. "Reviewing the documents, it appears that the firm wrongfully rejected the claim to avoid payment."Consequently, the commission ordered the firm to pay Rs 4 lakhs with 8% interest from January 2023 and Rs 3,000 for harassment.