Journalism of Courage
‘Denied’ insurance money for wife’s brain tumour surgery, man gets Rs 2.33 lakh
The District Consumer Commission stated that complainant had continuously renewed the health insurance policy since 2015 and that the policy was valid when his wife underwent brain tumour surgery.
The District Consumer Commission was dealing with a plea of husband regarding health insurance policy claim. (AI-generated Image)
A Delhi District Consumer Commission held Manipal Cigna Health Insurance liable for allegedly repudiating a woman’s brain tumour surgery claim on unproven allegations of non-disclosure of a pre-existing health complication. It directed the insurer to pay Rs 1.58 lakh to the complainant.
A bench of president Divya Jyoti Jaipuriar and member Rashmi Bansal also awarded Rs 50,000 compensation and Rs 25,000 as litigation costs.
“The conduct of the opposite party in repeatedly repudiating the claim on shifting grounds despite the clarification furnished by the treating doctor and despite the intervention of the Insurance Ombudsman clearly amounts to deficiency in service as defined under the Consumer Protection Act, 2019,” the commission said on July 30.
The order noted that the complainant is entitled to reimbursement of the balance admissible claim amount together with reasonable compensation for the harassment and mental agony suffered by him on account of the arbitrary action of the insurer.
Insurer rejects brain surgery claim
The complainant had been renewing a ProHealth Protect health insurance policy for his wife with Manipal Cigna since 2015. In August 2021, his wife underwent brain tumour surgery, incurring hospital expenses of Rs 4.58 lakh.
After another insurer reimbursed part of the expenses, he sought the remaining Rs 1.58 lakh from Manipal Cigna. The insurer rejected the claim, alleging that the insured had failed to disclose a pre-existing history of diabetes and mesenteric vein thrombosis dating back to 2014.
The complainant produced a treating doctor’s clarification stating that the thrombosis had existed only since 2016 and that the earlier medical record mentioning 2014 was an inadvertent error.
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The complainant submitted that even after the Insurance Ombudsman directed the insurer to reconsider the claim in light of the doctor’s clarification, the insurer rejected it again on a different ground, non-submission of documents, which was arbitrary because all required documents had already been furnished.
Insurer cites concealed medical history
The insurer contended that the insured had suppressed material facts by failing to disclose a history of diabetes mellitus and mesenteric vein thrombosis since 2014 while obtaining the policy, justifying repudiation of the claim.
After the Ombudsman’s order, it maintained that the claim could not be reconsidered because the complainant had allegedly failed to submit the required documents.
Repeated repudiation amounted to deficiency: Order
The commission noted that the insurer’s written statement had been filed beyond the statutory period prescribed under the Consumer Protection Act, 2019. As a result, it was taken off the record, leaving the complainant’s evidence unrebutted.
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It found that the complainant had continuously renewed the health insurance policy since 2015 and that the policy was valid when his wife underwent brain tumour surgery. The dispute centred on whether there had been suppression of material facts regarding pre-existing illnesses.
The commission observed that the discharge summary recorded the insured as having suffered from mesenteric vein thrombosis for the last four years, which pointed to 2016-17 rather than 2014. This was corroborated by the treating doctor’s clarification that the mention of 2014 in the medical record was inadvertent.
The Commission further observed that, despite the Insurance Ombudsman’s direction to review the claim, the complainant had resubmitted the doctor’s clarification and relevant documents. Yet, the insurer rejected the claim again on the ground of non-submission of documents without identifying any missing document. It held that this did not amount to a genuine reconsideration of the claim.
Since the allegation of non-disclosure was not proved, the commission held that the insurer had no basis to terminate the policy. It concluded that repeatedly repudiating the claim on shifting grounds, despite the doctor’s clarification and the Ombudsman’s intervention, amounted to deficiency in service under the Consumer Protection Act, 2019.
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Takeaway
This ruling reinforces that insurers cannot repudiate health insurance claims on unsubstantiated allegations of non-disclosure or shift reasons for rejection after a claim is challenged. It underscores that insurers must produce evidence, comply with Ombudsman directions, and fairly assess claims, failing which they may be held liable for deficiency in service.
Consumers facing similar grievances may contact the consumer helpline in their respective states (Delhi helpline: 011-23379146) or dial the National Consumer Helpline at 1915 for assistance.
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