Insurance firm told to pay Rs 3.18 lakh along with interest for denying cancer treatment claim

Amarjeet Kaur Walia of Chandigarh had stated in complaint that her husband Gurnam Singh Walia (since deceased) was insured with Cigna TTK Health Insurance Company Limited, which was valid from March 9, 2019 to March 8, 2020, and the sum assured under the policy was Rs 4,50,000. He (Gurman Singh Walia) was admitted to Fortis Hospital on January 7, 2020, and was discharged on January 10, 2020. During treatment, he was diagnosed as a case of “Carcinoma Right Buccal Mucosa” and he spent a total sum of Rs 3,55,304 on his treatment during his pre-hospitalisation and post-hospitalisation period. Thereafter, complainant Gurnam Singh Walia (since deceased) lodged a claim with the insurance company seeking reimbursement of the expenses incurred on his treatment, including the expenses incurred during pre-hospitalisation and post-hospitalisation period. However, his claim was rejected by the insurance company on June 27, 2020 on the ground that the complainant is having a history of betelnut chewing.

The insurance company in reply submitted that the complainant is covered under Manipal Cigna Health Insurance ProHealth Protect Policy and as per consultation paper, dated January 6, 2020, it is established that the patient gave history of betelnut chewing and the ailments requiring treatment due to use, abuse or a consequence or influence of an abuse of substance, intoxicant are not admissible under the policy, hence the claim stood rejected.

On hearing the matter, the commission noted that ‘No doubt, the OP (opposite party – Cigna TTK Health Insurance Company Limited) has relied upon prescription slip of the insured/patient issued by Dr Ashok Gupta, dated January 6, 2020, as exhibit that the patient gave history of betelnut chewing (Rajnigandha) but neither the affidavit of treating doctor in favour of opposite party was placed on record nor opposite party summoned and examined the treating doctor before this commission to prove the same. In the absence of any affidavit of the treating doctor or any other document to the effect that the betelnet chewing (Rajnigandha) falls under clause “VI Permanent Exclusions 15” of terms and conditions of the policy, reliance cannot be made just on prescription slips or passing reference in the notes of treatment as the prescription slips are not per se admissible in evidence as per the Indian Evidence Act, 1872.’

The commission added that it is not the first time that insurers like the OP (Opposite Party) in the present case by turning totally blind eye to the facts before them just concentrate on issuing/selling their policies but when the time comes to honour the claim they, with a view to repudiate/reject the same, resort to one or the other technicalities by totally ignoring that the purpose of taking insurance is not for any luxury but to cover up for some unforeseen eventuality.

“Moreover, it is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim.”

The commission thus ordered the insurance company to pay the complainant the claimed amount Rs 3,18,826 along with interest at 6 percent per annum from the date of rejection of claim which is June 27, 2020 till the date of its actual realisation, and to pay Rs 20,000 to the complainant as compensation for the harassment caused as well as litigation expenses.

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