2 weeks ago
Insurer to pay widow Rs 50 lakh after rejecting claim
A man bought a special health insurance policy that promised to pay a very large amount of money if he got a serious illness, like a heart problem.
The man later had a heart problem and had to stay in the hospital.
When he asked the insurance company to pay, the company refused his claim.
Sadly, the man passed away not long after.
His wife, now a widow, asked the insurance company again for the money, but it still would not pay.
The company said the medical papers were incomplete and hinted that the claim might be fake.
The wife took the matter to a consumer court in Fatehabad, Haryana, which listens to complaints about companies.
The court found that the company's own records showed the claim was marked as rejected even after the man had died.
The court said missing hospital records are the hospital's responsibility, not the patient's, and the company could not prove the claim was false.
So the court ordered the insurance company to pay the widow Rs 50 lakh and extra money for her legal costs.
The Fatehabad District Consumer Commission, Haryana, ordered Cigna TTK Health Insurance Company to pay Rs 50 lakh plus Rs 20,000 litigation costs to the widow of a man whose critical illness claim was rejected.
The man held a 'Lifestyle Protection–Critical Care Basic' policy with a sum assured of Rs 50 lakh, valid from September 27, 2018 to September 26, 2019.
He was hospitalised at Paras Hospital, Bhuna, Fatehabad, for a heart problem from November 24 to 28, 2020, and died on November 25, 2021.
The insurer's own records showed the claim was 'repudiated' on December 30, 2021, more than a month after the man's death, which the bench called careless handling amounting to deficiency in service.
The insurer argued medical criteria for Myocardial Infarction were not met and records suggested fraud, but the commission said it failed to prove the man did not die of a critical illness or had a pre-existing condition.
- Who
- The widow of an insured man (complainant) against Cigna TTK Health Insurance Company, with the case heard by a bench of president Gulab Singh and member O P Tuteja of the Fatehabad District Consumer Commission, Haryana.
- What
- The consumer commission ordered the insurer to pay the full Rs 50 lakh sum assured plus Rs 20,000 litigation costs for allegedly rejecting a critical illness claim carelessly and without checking facts.
- Where
- Fatehabad District Consumer Commission, Haryana; the insured was hospitalised at Paras Hospital, Bhuna, Fatehabad.
- When
- The order was passed on August 6; the policy ran from September 27, 2018 to September 26, 2019, the insured was hospitalised November 24–28, 2020, the claim was repudiated on November 5, 2021, and the man died on November 25, 2021.
- Why
- The commission held that the insurer failed to prove the man did not die of a critical illness or had a pre-existing condition, and that the unjustified delay caused the widow huge monetary loss, harassment, and mental agony.
Consumer Protection View
Insurer's View
Validity of the claim
Consumer Protection View
The husband died of heart disease, a condition falling within the critical illness cover, so the widow is entitled to the full Rs 50 lakh sum assured.
Insurer's View
The specific medical criteria for Myocardial Infarction (First Heart Attack of Specific Severity) were not fulfilled and required medical documents were missing, justifying refusal to pay.
Medical records and fraud allegations
Consumer Protection View
Any deficiency in medical records is the hospital's fault, not the patient's, and the insurer repudiated the claim carelessly without checking facts.
Insurer's View
Discrepancies in the medical records pointed to fabrication and a fraudulent claim, and the widow had suppressed material facts.
Burden of proof
Consumer Protection View
The insurer failed to lead any evidence that the man did not die of a critical illness or had a pre-existing condition before the policy began.
Insurer's View
The complaint was not maintainable and lacked cause of action, as the widow had not approached the commission with clean hands.
Key facts
- Insurer
- Cigna TTK Health Insurance Company
- Forum
- Fatehabad District Consumer Commission, Haryana
- Sum assured
- Rs 50 lakh (critical illness cover)
- Policy
- Lifestyle Protection – Critical Care Basic (Sep 27, 2018 – Sep 26, 2019)
- Hospitalisation
- Paras Hospital, Bhuna, Fatehabad (Nov 24–28, 2020)
- Claim repudiation
- November 5, 2021
- Insured's death
- November 25, 2021
- Litigation costs awarded
- Rs 20,000
Quotes
Fatehabad District Consumer Commission of Haryana
Haryana consumer commission body overseeing consumer disputes
“"The claim of the man was repudiated during his lifetime, but after his death, the claim was not settled by the opposite party on raising it by the complainant, which was not justified on the part of the opposite party, causing the complainant huge monetary loss, harassment, and mental agony, constraining her to file the complaint by incurring the cost of litigation."”
indianexpress.com
Sources
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