3 weeks ago
Manipal Cigna ordered to pay denied brain tumour surgery claim
A man in Delhi had a health insurance plan for his wife.
The plan was from a company called Manipal Cigna, and he had renewed it every year since 2015.
In August 2021, his wife had surgery to remove a brain tumour.
The hospital bill was Rs 4.58 lakh.
Another insurance company paid part of the bill.
The man then asked Manipal Cigna to pay the remaining Rs 1.58 lakh.
The company said no, claiming the wife had hidden that she was sick before getting the policy.
But the doctor said the earlier date in the records was a mistake.
The company kept changing its reasons for refusing, even after an official ombudsman told it to look again.
A consumer court in Delhi said the company must pay the money, plus extra compensation for the trouble and worry it caused.
A Delhi District Consumer Commission held Manipal Cigna Health Insurance liable for repudiating a brain tumour surgery claim on unproven allegations of non-disclosure.
The insurer was directed to pay Rs 1.58 lakh, along with Rs 50,000 compensation and Rs 25,000 litigation costs.
The insured woman underwent brain tumour surgery in August 2021, incurring hospital expenses of Rs 4.58 lakh; another insurer had already reimbursed part of the expenses.
Manipal Cigna alleged the insured concealed diabetes and mesenteric vein thrombosis since 2014, but the treating doctor clarified the thrombosis dated from 2016 and the 2014 mention was an inadvertent error.
The commission ruled that repeated repudiation on shifting grounds, despite the Insurance Ombudsman's direction to reconsider, amounted to deficiency in service under the Consumer Protection Act, 2019.
The order was issued on July 30 by a bench of president Divya Jyoti Jaipuriar and member Rashmi Bansal.
- Who
- A man in Delhi whose wife underwent brain tumour surgery, Manipal Cigna Health Insurance, and the Delhi District Consumer Commission.
- What
- The commission ordered Manipal Cigna to pay Rs 1.58 lakh, plus Rs 50,000 compensation and Rs 25,000 litigation costs, for wrongly rejecting the wife's health insurance claim.
- Where
- Delhi, India.
- When
- The order was passed on July 30; the surgery took place in August 2021, and the policy had been renewed since 2015.
- Why
- The insurer repudiated the claim on unproven allegations of non-disclosure and shifted its reasons for rejection despite a doctor's clarification and the Insurance Ombudsman's intervention, which the commission held to be deficiency in service.
Complainant / Consumers
Manipal Cigna / Insurer
Disclosure of pre-existing conditions
Complainant / Consumers
The insured did not conceal anything; her mesenteric vein thrombosis dated only from 2016 and the 2014 mention in the medical record was an inadvertent error, as clarified by the treating doctor.
Manipal Cigna / Insurer
The insured suppressed material facts by failing to disclose a history of diabetes mellitus and mesenteric vein thrombosis since 2014, which justified repudiating the claim.
Handling after Ombudsman intervention
Complainant / Consumers
All required documents had already been furnished, so rejecting the claim again on the ground of non-submission of documents was arbitrary.
Manipal Cigna / Insurer
The claim could not be reconsidered after the Insurance Ombudsman's order because the complainant allegedly failed to submit the required documents.
Key facts
- Insurer
- Manipal Cigna Health Insurance
- Policy
- ProHealth Protect, renewed continuously since 2015
- Claim reason
- Brain tumour surgery (August 2021)
- Hospital expenses
- Rs 4.58 lakh
- Amount ordered
- Rs 1.58 lakh
- Compensation
- Rs 50,000 for harassment and mental agony
- Litigation costs
- Rs 25,000
- Forum
- Delhi District Consumer Commission; key law: Consumer Protection Act, 2019
Sources
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