Mumbai: The District Consumer Disputes Redressal Commission, Mumbai Suburban, has delivered a strong judgment against Niva Bupa Health Insurance Company Ltd, ordering the insurer to reimburse a policyholder Rs66.50 lakh for expenses incurred during overseas cancer treatment. The commission found the company guilty of deficiency in service and engaging in unfair trade practice.
Juhu Man’s Overseas Cancer Claim Denied by Insurer
The case was filed by a Juhu resident, Alok Rajendra Bector, who had purchased the ‘Heartbeat – Family First Platinum Policy’ with worldwide coverage. The policyholder was undergoing treatment for colorectal cancer at a medical facility in the United States. Despite informing the insurer before travelling abroad and generally fulfilling policy conditions, the claim for the critical overseas treatment was unilaterally repudiated by the company.
The core of the dispute centred on the insurer’s attempt to leverage its own previous illegal actions. The commission noted that Niva Bupa had initially cancelled an earlier policy on the grounds of an alleged nondisclosure of asthma. Crucially, both the commission and an earlier ombudsman award in 2020 had established that asthma was an illness completely unrelated to the complainant’s cancer diagnosis and therefore had no bearing on the risk or the claim.
The court observed that Niva Bupa’s wrongful cancellation of the policy had the practical effect of preventing the policyholder from availing the cashless facility, a procedural requirement for such overseas claims. After failing to get justice, the policyholder filed a complaint before the commission, challenging the repeated rejection of his claim.
Commission Orders Niva Bupa to Pay ₹66.5 Lakh
The commission concluded that an insurer cannot rely on procedural gaps that are a direct result of its own unlawful act to later deny reimbursement. It has ordered Niva Bupa to pay the principal amount of Rs66.50 lakh. Additionally, the company must pay Rs30,000 as compensation and Rs10,000 towards litigation costs. Niva Bupa has been given a period of 60 days to comply, failing which the reimbursement amount will attract an interest rate of 6% per annum.
Commenting on the ruling, Advocate Rohit Lalwani and Sajal Khan, representing the complainant, said that an insurer cannot use technicalities resulting from its own wrongful conduct to avoid honouring a valid claim, sending an important message to both the insurance industry and consumers.
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