A district consumer forum in Delhi has directed Manipal Cigna Health Insurance to pay over Rs 2.33 lakh to a policyholder after holding the insurer liable for service deficiency for repeatedly denying a legitimate claim for brain tumour surgery.
The Delhi District Consumer Commission ruled on July 30 that the insurer arbitrarily rejected the reimbursement claim based on unproven assertions that the insured concealed pre-existing health conditions. The bench, comprising President Divya Jyoti Jaipuriar and member Rashmi Bansal, ordered the company to release the balance claim amount of Rs 1.58 lakh, along with Rs 50,000 as compensation for mental agony and Rs 25,000 toward litigation costs.
Unproven Claims Of Pre-Existing Illness
The case involves a policyholder who had continuously renewed a ProHealth Protect policy with Manipal Cigna since 2015. In August 2021, the policyholder’s wife underwent brain tumour surgery, incurring medical expenses amounting to Rs 4.58 lakh. After securing partial reimbursement from another insurance provider, the policyholder filed a claim with Manipal Cigna for the remaining Rs 1.58 lakh.
Manipal Cigna rejected the claim, alleging that the policyholder had suppressed material facts regarding a history of diabetes mellitus and mesenteric vein thrombosis dating back to 2014 when initially securing the coverage. In response, the policyholder presented a statement from the treating physician, who clarified that the reference to 2014 in medical records was an inadvertent error and that the thrombosis had actually developed in 2016. Hospital discharge records also described the condition as lasting for four years, pointing to an onset in 2016 or 2017.
Disregard Of Ombudsman Directives
Following an intervention by the Insurance Ombudsman instructing Manipal Cigna to review the claim in light of the doctor’s statement, the insurer rejected the claim a second time. The company cited non-submission of required documents as the reason for its second rejection, despite the policyholder having submitted all relevant records and the insurer failing to specify any missing paperwork.
During the proceedings, the commission noted that Manipal Cigna failed to submit its written response within the statutory timeline prescribed under the Consumer Protection Act, 2019. As a result, the insurer’s submission was excluded from the record, leaving the policyholder’s evidence uncontested.
Legal Standpoint And Financial Penalty
The commission observed that shifting the grounds for repudiation despite medical clarification and ombudsman directives failed to constitute a genuine review of the claim. It concluded that repeatedly denying claims on unsubstantiated grounds amounts to a clear deficiency in service.
The ruling reinforces that health insurance providers cannot cancel policies or repudiate claims without concrete evidence of pre-existing condition non-disclosure, nor can they alter rejection justifications once challenged.
