Wrongly denied cancer coverage, patient wins Rs 12.35 lakh payout from hospital, insurer

The order said that based on the findings, the opposite parties were guilty of deficiency in service.

The complainant had purchased a health insurance policy from Niva Bupa Health Insurance for the period from August 30, 2024, to August 29, 2025. Before buying the policy, he had undergone a medical consultation in 2022 for back pain and had disclosed the relevant medical reports to the insurer.

In March-April 2025, he was diagnosed with a malignant neoplasm of the colon (colon cancer) and was admitted to Yashoda Superspeciality Hospital, Ghaziabad, where he incurred medical expenses exceeding Rs 5.36 lakh.

Policy cancelled, irregularities by hospital

He submitted all the required documents to the insurer for cashless treatment. However, Niva Bupa allegedly cancelled his policy, citing 20-30 per cent coronary stenosis (blockage in heart), which the complainant claimed was a treatable condition that had already been disclosed and had no connection with his cancer treatment.

The complainant further alleged that the hospital engaged in several irregularities, including issuing bills without GST details, unlawfully detaining him until payments were made, and raising arbitrary charges for medicines and treatment. During a subsequent admission on April 9, 2025, the hospital allegedly collected Rs 5.72 lakh, even though the insurer had approved only Rs 3.80 lakh.

After surgery-related complications, he was admitted again on April 20, 2025, but the insurer refused to cover the expenses. He also claimed that the hospital forcibly recovered additional amounts from him and that he incurred further expenses on medical tests and taxi charges. After receiving no relief despite approaching the President’s Secretariat, the Prime Minister’s Office, the insurance ombudsman, and other authorities, the complainant filed a consumer complaint.

Yashoda Hospital, its employee Dr Vivek Kumar, and Niva Bupa’s grievance team did not appear before the commission, due to which the case continued without hearing their side.

The commission allowed the complaint, holding Yashoda Superspeciality Hospital, Niva Bupa Health Insurance, and others guilty of deficiency in service. It directed them to jointly refund Rs 11.63 lakh with 9 per cent interest, pay Rs 50,000 compensation, Rs 22,000 litigation costs, continue the insurance policy, and comply within 45 days, failing which 12 per cent interest would apply.

Takeaway

This ruling reinforces that insurers and hospitals cannot evade accountability by remaining absent from consumer proceedings. It also highlights that unilateral policy cancellation, denial of genuine medical claims, and unfair hospital billing can amount to a deficiency in service. The decision underscores that consumer forums will grant relief based on unrebutted evidence when opposing parties fail to contest the allegations.

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.