The Delhi Consumer Commission has mandated Manipal Cigna Health Insurance to pay Rs 1.58 lakh after the insurer unjustly denied a claim for a brain tumour surgery. The commission ruled that the insurer’s shifting grounds constitute a deficiency in service under the Consumer Protection Act.
Key Takeaways
- Manipal Cigna ordered to pay Rs 1.58 lakh for denied claim.
- Repeated shifting of denial grounds deemed deficiency in service under Consumer Protection Act.
- Policy was valid; denial based on unproven pre‑existing condition.
Case Background
A Delhi District Consumer Commission heard a petition from a husband whose wife underwent brain tumour surgery in August 2021. The husband had continuously renewed the ProHealth Protect policy with Manipal Cigna since 2015, and the policy was active at the time of surgery.
Claim and Insurer’s Argument
The total hospital bill amounted to Rs 4.58 lakh. After another insurer reimbursed part of the expense, the husband sought the remaining Rs 1.58 lakh from Manipal Cigna. The insurer rejected the claim, alleging non‑disclosure of diabetes and mesenteric vein thrombosis dating back to 2014.
Doctor’s Clarification and Commission Findings
The petitioner produced a treating doctor’s clarification stating that the thrombosis existed only since 2016 and that the 2014 entry was a clerical error. The Insurance Ombudsman directed the insurer to reconsider, but the insurer again rejected the claim, this time citing alleged non‑submission of documents—despite all required paperwork having already been provided.
Commission’s Decision
The commission observed that the insurer’s written statement was filed beyond the statutory period, leaving the petitioner’s evidence unchallenged. It concluded that the insurer had no basis to terminate the policy and that the repeated repudiation on shifting grounds amounted to a deficiency in service under the Consumer Protection Act, 2019.
Why This Matters
BozokMedia analysis shows that this ruling sets a strong precedent for insurance claimants, compelling insurers to substantiate any denial with concrete evidence and to obey Ombudsman directions, else they risk liability for deficiency in service.
"Denial of claims on unsubstantiated pre‑existing condition allegations is now a legal risk for insurers," says consumer law expert Dr. Ananya Mehta.
Frequently Asked Questions
- Can policyholders prevent future unjust denials?
Yes, by maintaining comprehensive medical records and promptly following Ombudsman directives. - Will this decision affect other insurance policyholders?
The judgment creates a judicial benchmark, urging insurers to adopt more transparent claim‑handling practices.
