While rejecting the cancer treatment claim citing the patient’s “habit of chewing” betel leaf (Rajnigandha), the Chandigarh Consumer Disputes Redressal Commission directed an insurance company to pay Rs 3.18 lakh along with interest to the widow of the insured, observing that the insurance company relied only on a prescription coupon without proper evidence from the treating doctor.
The Commission noted that insurers often “show green pastures” to customers at the time of selling insurance policies but later “invent excuses” to deny claims.
Amarjit Kaur Walia of Chandigarh stated in her complaint that her husband Gurnam Singh Walia (since deceased) was insured with Cigna TTK Health Insurance Limited, which was in force from March 9, 2019 to March 8, 2020, and the amount insured under the policy was Rs 4,50,000. He (Gurman Singh Walia) was admitted to Fortis Hospital on 7 January 2020 and was discharged on 10 January 2020. During treatment, he was diagnosed as a case of “Right Buccal Mucosa Carcinoma” and a total amount of Rs 3,55,304 was spent on his treatment during pre-hospitalization and post-hospitalization period. Subsequently, complainant Gurnam Singh Walia (since deceased) filed a claim with the insurance company seeking compensation for the expenses incurred in his treatment, including expenses incurred during the pre-hospitalization and post-hospitalization period. However, the insurance company rejected his claim on 27 June 2020 on the grounds that the complainant had a history of chewing betel nut.
The insurance company responded in reply that the complainant is covered under Manipal Cigna health insurance policy ProHealth Protect and as per consultation paper dated 6th January 2020, it is established that the patient has given history of betel nut chewing and diseases requiring treatment due to use or misuse or result or effect of drug abuse, intoxicants are not admissible under the policy and hence the claim was rejected.
Hearing the matter, the panel noted that “There is no doubt that the OP (opposite party – Cigna TTK Health Insurance Company Limited) relied on the prescription voucher of the insured/patient issued by Dr. Ashok Gupta, dated January 6, 2020, as evidence that the patient had given a history of chewing betel nut (Rajnigandha) but no affidavit of the treating physician was recorded in favor of the opposite party and the opposite party was not called and examined by the treating physician before this Commission to prove the same. In the absence of any affidavit of the treating physician or Any other document stating that Betel Chew (Rajnigandha) falls under ‘6th Standing Exclusions No. 15′ of the Policy Terms and Conditions, reliance cannot be placed solely on prescription coupons or passing reference in treatment notes as prescription coupons are inadmissible per se in evidence as per the Indian Evidence Act, 1872.’
The Commission added that it is not the first time that insurance companies like the OP (opposite party) in the present case have completely overlooked the facts before them and focus only on issuing/selling their insurance policies, but when the time comes to honor the claim, they, with a view to repudiation/denial, resort to one or the other technical measures by completely ignoring that the purpose of obtaining insurance is not for any luxury but to cover up some unforeseen eventualities.
“Moreover, it is usual for the insurance company to show all kinds of greener pastures to the customer at the time of selling insurance policies, and when it comes to paying the insurance claim, they invent all kinds of excuses to reject the claim.”
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The Commission therefore ordered the insurance company to pay the claimed amount of Rs 3,18,826 to the complainant with interest at 6 per cent per annum from the date of rejection of the claim which is June 27, 2020 till the date of its actual investigation, and to pay Rs 20,000 to the complainant as compensation for the harassment caused as well as litigation expenses.
(Tags for translation) Denial of Insurance for a Cancer Patient Chandigarh
