Delivering a stringent order against Niva Bupa Health Insurance Company Ltd, the Mumbai suburban district consumer disputes redressal commission has directed the insurer to reimburse ₹66.50 lakh to a Juhu resident whose overseas cancer treatment claim was rejected on grounds later found to be baseless. The commission held the insurer guilty of deficiency in service and unfair trade practice after concluding that the policy was cancelled arbitrarily and the reimbursement claim was denied using procedural grounds that arose solely because of the insurer’s own unlawful actions.
The complainant, Alok Rajendra Bector, had purchased Niva Bupa’s 'heartbeat – family first platinum policy' in 2017, a comprehensive health insurance plan offering worldwide coverage including the US. In August 2018, while the policy was active, Mr Bector was diagnosed with colo-rectal cancer. He sought specialised treatment at the Memorial Sloan Kettering Cancer Research Centre in the US and informed the insurer about his diagnosis as well as his planned overseas treatment, as required under the policy.
However, instead of processing his claim, Niva Bupa repudiated it by alleging that Mr Bector had failed to disclose a pre-existing condition, asthma. The commission found that this allegation had no medical relevance to the cancer diagnosis. It noted that the company 'failed to prove that the illness, asthma, had any nexus to the colo-rectal cancer treatment for which the claim arises, or that disclosure would have altered the opposite party’s decision to provide overseas cover'.
The insurer cancelled Mr Bector’s policy in December 2019, a decision later challenged before the insurance ombudsman. In March 2020, the Ombudsman held that asthma was entirely unrelated to the life-threatening cancer diagnosis and ruled that the cancellation was unjustified. A portion of the earlier claim was reimbursed, establishing that Niva Bupa’s cancellation had no legal or medical basis.
Despite this finding, the insurer rejected Mr Bector’s subsequent claim of over ₹88 lakh for his extended treatment in the US between March 2019 and March 2020. Niva Bupa argued that the policy allowed overseas treatment only through a cashless facility and that reimbursement was not permitted. The commission rejected this argument, observing that the insurer had itself cancelled the policy before Mr Bector could apply for the required pre-authorisation.
Niva Bupa's own actions had made cashless treatment impossible, the commission says, and could not rely on a procedural rule to deny coverage when the claimant had been forced into a reimbursement route by circumstances created by the insurance company.
The commission also addressed the insurer’s jurisdiction objection, noting that under the Consumer Protection Act, jurisdiction depends on the value of the consideration paid—in this case the cumulative premium, which was below ₹50 lakh—and not on the claimed reimbursement amount.
The commission held that Mr Bector had been wrongfully deprived of policy benefits at a time of urgent and life-saving medical need, causing financial strain and mental trauma while he was undergoing cancer treatment abroad.
It directed Niva Bupa to reimburse ₹66.50 lakh within 60 days, failing which the amount will attract interest at 6% annually. The insurer has also been ordered to pay ₹30,000 as compensation and ₹10,000 towards litigation costs.
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