The Fatehabad District Consumer Commission in Haryana has ordered Cigna TTK Health Insurance Company to pay Rs 50 lakh to the widow of a policyholder whose critical illness claim was wrongfully turned down. Ruling that the insurer committed a clear deficiency in service, the consumer forum directed the firm to disburse the full insured amount alongside Rs 20,000 to reimburse the legal expenses incurred by the complainant.
A two-member bench comprising Commission President Gulab Singh and Member O P Tuteja announced the decision on August 6, ruling that the insurance provider caused substantial financial harm, harassment, and mental distress to the claimant. The panel noted that the company’s failure to settle the legitimate claim forced the widow to pursue formal legal action to recover funds that should have been made available for her support.
Flawed Claim Rejection Process
The commission pointed to significant administrative shortcomings in the insurer’s handling of the case. Records examined during the proceedings revealed that although the insured individual passed away on November 25, 2021, internal documentation from the insurance company listed a claim rejection date of December 30, 2021. The bench stated that repudiating a claim more than a month after the policyholder’s death reflected careless evaluation and a failure to verify basic facts, which in itself constituted a service deficiency.
Policy Terms and Claim History
The case originates from a “Lifestyle Protection–Critical Care Basic” policy purchased from Cigna TTK Health Insurance Company, which carried a sum assured of Rs 50 lakh for critical illnesses and was valid from September 27, 2018, to September 26, 2019. During the coverage period, the policyholder suffered a cardiac condition and received inpatient treatment at Paras Hospital in Bhuna, Fatehabad, from November 24 to November 28, 2020.
The policyholder submitted a medical claim during his lifetime, but the insurer rejected it on November 5, 2021. Following his death 20 days later from heart disease, his widow, identified in court records as Suman, pursued the claim on the grounds that cardiac mortality fell directly within the critical illness provisions of the policy. After sending a formal legal notice on September 6, 2022, which received neither a reply nor payment, she filed a complaint with the district commission.
Insurer Defense and Panel Findings
In its submission to the commission, Cigna TTK denied any deficiency in service and argued that the complaint was non-maintainable. The company alleged that the applicant suppressed material facts and failed to meet the required medical parameters for Myocardial Infarction (First Heart Attack of Specific Severity). The insurer further claimed that missing documentation and inconsistencies in medical records suggested fabrication and fraud, justifying its decision to withhold payment.
The commission rejected the insurer’s defense, observing that the critical illness coverage itself was non-controversial and that the initial claim raised during the policyholder’s lifetime was established by the firm’s own rejection letter. The bench affirmed that patients are not responsible for maintaining hospital files and that any administrative gaps in medical records lie with the healthcare facility rather than the patient or beneficiary. Furthermore, the panel held that the insurer failed to produce evidence showing that the policyholder did not die from a critical illness or that he suffered from a pre-existing condition prior to policy inception.
