The Kangra District Consumer Disputes Redressal Commission in Himachal Pradesh has directed Niva Bupa Health Insurance Company Limited to pay a female policyholder over Rs 2.65 lakh following the improper rejection of her surgery claim. A bench comprising Commission President Hemanshu Mishra and members Arti Sood and Narayan Thakur issued the ruling on July 25, determining that the insurer committed a deficiency in service and engaged in an unfair trade practice by resetting a policy waiting period.
Under the commission’s directive, Niva Bupa must reimburse the policyholder her full treatment claim of Rs 2,30,124, along with 9 percent annual interest calculated from the filing date of the complaint until actual realization. The panel also ordered the insurer to pay Rs 20,000 as compensation for mental agony and harassment, as well as Rs 15,000 to cover her litigation expenses.
Background of the Medical Claim
The policyholder was diagnosed with an ovarian cyst in July 2024 and was admitted to the hospital from August 13 to August 14, 2024, to undergo surgical removal of the cyst. Her total medical expenditure reached Rs 2,30,124, which consisted of Rs 2,19,124 in hospital and surgical costs and Rs 11,000 for an MRI scan.
After submitting her reimbursement request, Niva Bupa rejected the claim in an email sent on August 23, 2024. The insurance company cited Clause 6.1(a) of the policy, treating the ovarian cyst as a pre-existing condition bound by a 36-month waiting period. The insurer argued that the cyst was pathologically connected to an open hysterectomy surgery the woman had undergone in 2020. The company asserted that porting a policy does not waive specific waiting periods if a condition stems from prior medical history, and that general regulatory guidelines on moratorium periods do not override explicit policy exclusions.
Policy Continuity and Commission Findings
The consumer forum rejected the insurer’s justification, noting that the woman had maintained continuous health insurance coverage without interruption since July 30, 2019. Her initial coverage was issued by Star Health and Allied Insurance Company Limited, under which she had her 2020 surgery. On August 8, 2022, her policy was ported to Niva Bupa with all continuity benefits transferred. Her relevant Family Floater policy was active from July 30, 2024, to July 29, 2025.
The commission emphasized that under Insurance Regulatory and Development Authority of India (IRDAI) guidelines, an insurer accepting a ported policy is required to carry forward and credit waiting periods completed under the previous insurer. By the time of her treatment in August 2024, the woman had completed more than five years of uninterrupted coverage, meaning the 36-month pre-existing condition waiting period had long expired. The forum ruled that relying on indirect medical links to restart waiting periods post-portability was arbitrary, legally unsustainable, and violated statutory consumer protections.
