Stay updated with medical advances, consumer panel tells insurer

Ahmedabad: A consumer commission in Ahmedabad has asked an insurance company to remain updated on advancements in medical technology and treatment after it rejected a claim for cancer treatment, calling it an “unproven” therapy, even though the treatment was approved by the US Food and Drug Administration (USFDA).The commission also observed that a well-qualified doctor would never administer a treatment that was not proven or documented. With these observations, it directed the insurer to reimburse the claim for prostate cancer treatment.A resident of Naranpura in Ahmedabad was admitted to a corporate hospital in Aug 2022 for 177 Lu-PSMA RLT injection therapy for advanced prostate cancer treatment and paid Rs 1.38 lakh for it.

He was covered under a Rs 5 lakh health insurance policy issued by New India Assurance Co Ltd and sought reimbursement of the medical expenses.The insurer rejected the claim, stating that the treatment was unproven because it lacked sufficient medical documentation to establish its efficacy.The patient then approached the District Consumer Disputes Redressal Commission, Ahmedabad (Main). While hearing the case, the commission searched online to verify whether the treatment had been approved and found that the USFDA had approved it in March 2022 as a targeted radioligand therapy for adults with PSMA-positive metastatic castration-resistant prostate cancer who had already undergone androgen receptor pathway inhibition and taxane-based chemotherapy.

The commission stated in its order: “Looking to the above explanation, we do not find that the procedure is unproved or unknown. There are detailed discussions on this treatment/therapy on Google, and it shows great benefit to patients in terms of recovery and survival. A well-qualified doctor would not perform any procedure that is not proved or documented.”The commission further noted that the Insurance Regulatory and Development Authority of India (IRDAI) has also removed certain procedures and treatments from the list of exclusions from hospitalisation coverage due to advancements in medical technology.It observed: "With advancement in technology and treatments, we are of the opinion that the insurer should also be updated and pay for such claims. Once the insurer accepts to indemnify the loss of the insured after accepting the premium for the mediclaim policy, it cannot back out under such exclusion clauses by saying the treatment is unproved.”It further added: “No qualified doctor would attempt to perform a procedure or surgery unless it is proved and successful.”The commission noted that the insurer failed to produce any evidence supporting its decision to reject the claim. It ordered the company to reimburse the treatment cost with 8% annual interest and also directed it to pay the consumer Rs 8,000 towards compensation for mental agony and litigation costs.