The North Delhi District Consumer Disputes Redressal Commission-I has ordered Manipal Cigna Health Insurance Company to pay more than Rs 14.6 lakh, calling its rejection of an emergency medical claim both arbitrary and unreasonable. The commission ruled that an insurer cannot deny coverage by demanding diagnostic reports that are impossible to obtain during active, life-saving medical procedures.
The decision comes after Kanak Lata and her two minor sons filed a complaint against the insurer. The case dates back to April 2021, when Lata’s husband, Pankaj Srivastava, died of sudden cardiac arrest hours after seeking treatment for severe respiratory distress.
Emergency Admission and Death
Srivastava, who had secured a group health insurance policy linked to a home loan in 2019, fell ill during the pandemic in April 2021. After initially experiencing a cough and sore throat on April 1, his condition deteriorated over the next two days, culminating in severe breathlessness on the morning of April 4.
He was initially evaluated at a flu clinic at Aruna Asaf Ali Government Hospital, where a rapid Covid-19 test returned negative. However, his health worsened after he returned home, and he was rushed back to the hospital’s emergency ward later that night.
Hospital records showed that Srivastava arrived at the casualty department in a gasping state, with critically low oxygen levels and unrecordable blood pressure and pulse. Medical staff immediately initiated emergency cardiopulmonary resuscitation (CPR) and other resuscitative procedures. Despite their efforts, doctors were unable to revive him, and he was declared dead at 11:15 p.m. on April 4, 2021. The official death summary listed sudden cardiac arrest as the cause of death.
Rejection Based on Technicalities
Following the tragedy, Lata submitted a claim under the policy, which included Rs 7 lakh for critical illness, Rs 5 lakh for an education fund, and Rs 10,000 for funeral expenses. However, Manipal Cigna rejected the claim on November 18, 2021.
The insurer argued that sudden cardiac arrest was not listed as a critical illness under the policy. It asserted that the family had failed to provide ECG reports, cardiac enzyme tests, troponin test results, or a post-mortem report to prove that Srivastava suffered a myocardial infarction, which was covered under the contract.
Commission Dismisses Insurer’s Arguments
The consumer commission, comprising President Divya Jyoti Jaipuriar and members Ashwani Kumar Mehta and Harpreet Kaur Charya, strongly rejected the insurance company’s reasoning. The panel declared that demanding tests requiring a stable period of time from a patient undergoing active CPR is medically absurd and humanly impossible.
The commission also ruled that post-mortem examinations are not mandatory in cases of natural death and cannot be used as a basis to reject a claim. It noted that the insurer failed to produce any expert medical opinion to support its distinction between a cardiac arrest and myocardial infarction in this context, adding that such complex technical terms must be clearly explained to consumers when selling policies rather than being used to deny benefits later.
Compensation and Additional Penalties
The commission directed Manipal Cigna to pay Rs 12.10 lakh in policy benefits, along with 9 percent simple interest per annum from November 18, 2021. It also awarded Rs 1 lakh in compensation for mental agony and Rs 25,000 for litigation costs.
Furthermore, the panel penalized the insurer an additional Rs 5 lakh for using insensitive language in its rejection letter, which claimed the deceased was accustomed to death. The commission described the phrasing as grammatically grotesque, lacking in logic, and deeply insensitive to a grieving family, ordering the fine to be deposited in the Consumer Welfare Fund within 45 days.
The lender, Indiabulls Rural Finance, was also ordered to pay Rs 1 lakh in compensation and Rs 25,000 in litigation costs for engaging in unfair trade practices by initiating loan recovery actions against the widow while her insurance claim was still pending. The commission instructed that the insurer’s payout must first be adjusted toward the outstanding home loan before releasing the remaining funds to the family.
