The Fatehabad District Consumer Commission of Haryana has directed Cigna TTK Health Insurance Company to pay Rs 50 lakh to the widow of a man whose critical illness claim was allegedly rejected, and observed that the Insurer caused the widow huge monetary loss, harassment, and mental agony, constraining her to file the complaint by incurring the cost of litigation.
A bench of president Gulab Singh and member O P Tuteja, holding the insurer deficient in service, also awarded Rs 20,000 litigation costs to the widow.
“The claim of the man was repudiated during his lifetime, but after his death, the claim was not settled by the opposite party on raising it by the complainant, which was not justified on the part of the opposite party, causing the complainant huge monetary loss, harassment, and mental agony, constraining her to file the complaint by incurring the cost of litigation. Had the opposite party paid the claim to the complainant in time, she would have been able to utilise the same for her benefit,” the commission said on August 6.
The order noted that despite receiving her legal notice on September 6, 2022, the insurance company didn’t pay up. Worse, its own records showed it had “repudiated” the claim on December 30, 2021, more than a month after the man had already died. The bench held that this mismatch showed the company rejected the claim “carelessly”, without even checking the facts properly, which itself amounted to a deficiency in service.
Widow challenged wrongful claim repudiation
The husband of the complainant had purchased a health insurance policy titled “Lifestyle Protection–Critical Care Basic” from Cigna TTK Health Insurance Company, valid from September 27, 2018 to September 26, 2019, with a sum assured of Rs 50 lakh covering critical illness.
While the policy was in force, the man suffered a heart problem and was hospitalised at Paras Hospital, Bhuna, Fatehabad, from November 24, 2020 to November 28, 2020. He filed a medi-claim with the insurer, but the company repudiated it on November 5, 2021. Later, on November 25, 2021, the man passed away.
Following her husband’s death, the woman, as his widow, stepped forward to pursue the claim. She contended that the repudiation was wrongful and contrary to law and facts, since her husband had died of heart disease, a condition falling within the critical illness cover, entitling her to the full sum assured of Rs 50 lakh. She sent a legal notice to the company, but received no response or payment, prompting her to approach the consumer commission alleging deficiency in service, negligence, financial loss, harassment, and mental agony.
Medical criteria not fulfilled: Insurer
The insurance company, in its defence, denied any deficiency in service. It argued the complaint was not maintainable and lacked cause of action, claiming Suman had not approached the commission with clean hands and had suppressed material facts.
It further contended that specific medical criteria for Myocardial Infarction (First Heart Attack of Specific Severity) had not been fulfilled, that required medical documents were missing, and that discrepancies in the medical records pointed to fabrication and a fraudulent claim, justifying its refusal to pay.
Deficiency in medical record not patient’s fault: Order
The commission noted that the policy’s coverage under “critical illness” was undisputed. During his lifetime, the life assured was hospitalised at Paras Hospital, Bhuna, and had raised a medical claim, proved by the insurer’s own repudiation letter dated November 5, 2021.
The commission noted that if there was any deficiency in the medical records, it was not the fault of the life assured or the complainant after his death; rather, it lay with the hospital, since a patient isn’t responsible for maintaining hospital records.
“The insurer alleged discrepancies suggesting fabrication and fraud but failed to lead any evidence to prove the life assured had not died of critical illness, or that he had a pre-existing condition before the policy began,” the order stated.
The order stated that if there was some deficiency in the medical record, then it was not the fault of the man after his death by the complainant; rather, it was on the part of the hospital concerned. The man, being the patient, is not supposed to maintain the record of the hospital.
Takeaway
The judgment matters because it reinforces that insurers cannot deny critical illness claims merely by pointing to alleged medical-record discrepancies without proving fraud or a pre-existing condition. The Commission also recognised that patients cannot be held responsible for maintaining hospital records, protecting policyholders and beneficiaries from unjustified claim repudiation.
Consumers facing similar grievances may contact the consumer helpline in their respective states (Haryana helpline: 1800-180-2087) or dial the National Consumer Helpline at 1915 for assistance.
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A Haryana District Consumer Commission was dealing with a plea of a widow seeking health insurance claim money. (AI-generated Image) 
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