In a significant ruling that underscores the rights of policyholders, the District Consumer Disputes Redressal Commission (DCDRC) in Noida has ordered Cigna TTK Health Insurance Company to pay a claim it had earlier rejected as 'fraud'. The insurer must pay the claim amount of nearly Rs 35,000 along with 6% annual interest from 2019 and litigation costs.
The Case of the Rejected Dengue Claim
The dispute dates back to a health insurance policy purchased by Sector 53 resident Anil Kumar. He bought a family health cover from Cigna TTK Health Insurance Company Limited on March 31, 2018, which included his wife Bhagyashri Tiwary and daughter Jahnvi Tiwary.
Later that year, his wife contracted dengue fever and was admitted to Prabha Hospital on November 3, 2018. After her discharge on November 7, the family incurred medical expenses totalling Rs 34,823 for hospital charges, medicines, and lab tests. Kumar duly filed a claim for reimbursement with the insurer.
Insurer's 'Fraud' Allegation and Consumer's Fight
To Kumar's shock, Cigna TTK rejected his claim on December 13, 2018, branding it as a 'fraud claim'. Determined to fight the decision, Kumar obtained a detailed medical report from the treating doctor to substantiate his case. He asserted that no representative from the insurance company ever contacted him to verify or challenge the submitted documents.
When the matter reached the consumer commission, the insurer filed a response claiming an investigation found all documents and treatment details to be incorrect. They referenced a different policy purchased in February 2017 and a hospitalization at Om Hospital in December 2017 for a urinary tract infection, arguing the treatment was suspicious.
Court Finds Critical Lapse in Verification
Presided over by President Anil Kumar Pundir and Member Anju Sharma, the commission scrutinized the arguments. They discovered a glaring error: the insurance company was arguing about a completely different policy and hospitalization unrelated to Kumar's claim.
The commission noted that while the claimant was discussing a policy from March 2018 and a dengue hospitalization in November 2018, the insurer was referencing a 2017 policy and a UTI case. This mismatch proved the insurer had not properly examined the claimant's documents.
The Verdict and Directive
Disposing of the matter on December 18, the commission held that rejecting the claim without proper verification constituted a deficiency in service under the Consumer Protection Act. The order stated the insurer mishandled the case papers.
The final directive mandates Cigna TTK to:
- Pay the claim amount of approximately Rs 35,000.
- Add interest at the rate of 6% per annum from 2019.
- Pay litigation costs of Rs 2,000 to the complainant.
- Complete all payments within 30 days of the order.
This ruling serves as a strong reminder to insurance companies to conduct thorough and accurate investigations before denying claims, and it reinforces the legal recourse available to consumers facing unjust rejections.
