Niva Bupa Ordered to Pay ₹16 Lakh After NCDRC Rules in Favor of Policyholder, Cites Lack of Evidence in Claim Denial

 

New Delhi, November 13, 2024 — In a notable consumer rights ruling, the National Consumer Disputes Redressal Commission (NCDRC) decided in favor of Mahipal Chaudhary against Max Bupa Health Insurance Co (Now Niva Bupa Health Insurance)., ordering the insurer to pay his wife’s medical claim of ₹16,06,946 for Parkinson’s disease treatment. The case sheds light on the duties of disclosure in health insurance and underscores the responsibility of insurers to back up their claim rejections.

Case Background 🏥

Mahipal Chaudhary filed a claim with Max Bupa (Now Niva Bupa) for his wife’s Parkinson’s disease treatment, only to face rejection. Max Bupa argued that Chaudhary had failed to disclose his wife's pre-existing symptoms—such as tremors, difficulty in movement, and speech problems—which dated back to 2006. They claimed this lack of disclosure violated the terms of the insurance contract. In support, Max Bupa referred to a discharge summary from Jaslok Hospital, which outlined these symptoms, implying the insured was aware of her condition.

However, Chaudhary contested the rejection, claiming he was unaware of any Parkinson’s diagnosis at the time of policy purchase. He argued that the discharge summary merely recorded symptoms and did not equate to a prior diagnosis, asserting that Max Bupa had no grounds to deny the claim.

Insurer's Arguments 💼

Max Bupa’s (Now Niva Bupa) case rested on several key points:

• Non-Disclosure: They argued Chaudhary failed to disclose his wife’s longstanding symptoms.
• Discharge Summary Evidence: The insurer claimed that the discharge summary documented symptoms dating back several years, which should have been disclosed.
• Policy Exclusions: Max Bupa cited policy exclusions for pre-existing conditions and argued that Parkinson’s was among these excluded conditions.

Observations by NCDRC 👨‍⚖️

In a detailed ruling, the NCDRC made several important observations that highlighted the obligations of insurers:

1. Burden of Proof on Insurers: The court emphasized that it’s the insurer's duty to prove allegations of non-disclosure. Simply pointing to symptoms in a discharge summary does not suffice as proof of concealment without evidence that the insured was knowingly aware of a specific diagnosis.

2. Benefit of Doubt to Insured: The court ruled that since there was no evidence Chaudhary’s wife had been formally diagnosed with Parkinson’s disease at the policy’s inception, the benefit of doubt should go to the insured. The court noted that symptoms alone, without a concrete diagnosis, do not constitute grounds for policy rejection.

3. Duty of Insurer to Conduct Thorough Checks: Notably, Max Bupa had conducted a medical examination when the policy was issued, which did not raise any concerns. The NCDRC observed that a thorough assessment at that stage would have detected any health issues, putting the onus on the insurer to clarify any discrepancies upfront.

4. Policy Exclusion Clauses: The court further highlighted that insurers cannot retrospectively apply exclusions without a clear diagnosis. Exclusion clauses, the court stated, should only be applied when backed by unambiguous medical evidence.

Impact of the Ruling 📜

This ruling underscores consumer protection principles in insurance, emphasizing the insurer’s responsibility to prove allegations of non-disclosure. It’s a victory for policyholders, as the judgment could influence future cases by requiring insurers to base claim rejections on strong, clear evidence rather than assumptions or incomplete records.

As the insurance industry adapts to this judgment, policyholders may feel more secure knowing they are entitled to fair treatment and that insurers must meet a high standard of proof before denying coverage.

Disclaimer: This article is based on the decision rendered by the National Consumer Disputes Redressal Commission (NCDRC) in Revision Petition No. 829 of 2018, dated 06-11-2024, in the case of Mahipal Chaudhary vs. Max Bupa Health Insurance Co. Ltd. The content provided herein is for informational purposes only and does not constitute legal advice. Any interpretation or reference to the case should be understood in the context of the facts and circumstances involved in the specific case mentioned.

Image Disclaimer: The image featured in this article is AI-generated and does not represent a real-world depiction of any individuals or events. It is created for illustrative purposes only.