Bengaluru: A senior citizen’s health insurance claim for cancer treatment was denied, leading to a prolonged dispute. The II additional Bengaluru Urban district consumer disputes redressal commission has now held the insurer guilty of deficiency in service, and ordered it to reimburse the expenses with interest and compensation, totalling almost Rs 5 lakh.The saga began on April 1, 2023, when Manjula Chandranth Sumathi, a 70-year-old resident of Banashankari I Stage, purchased a health insurance policy from Star Health and Allied Insurance Company Ltd, declaring pre-existing conditions of diabetes and hypertension. She paid Rs 45,825 (including tax) for a Rs 10 lakh cover, valid till March 31, 2024. The policy was renewed on March 12, 2024, for the period from April 1, 2024 to March 31, 2025, on payment of the same premium. But in May 2024, Manjula developed a lump in her right breast and, on medical advice, was admitted to Excel Care Hospital on July 7, 2024. She underwent treatment for breast cancer as an inpatient from July 7 to July 9. She paid almost Rs 3 lakh towards the hospital’s final bill and an additional Rs 2 lakh towards pharmacy, bed, and related charges.On July 22, her daughter and nominee, Swetha Sumathi, 39, approached the insurer’s Jayanagar branch seeking reimbursement. The insurer issued a query letter dated July 27, followed by a communication on Aug 22 seeking documents, all of which were submitted. However, within two days, the claim was repudiated, alleging non-disclosure of past illness, and a subsequent notice was issued proposing cancellation of the policy.Manjula contended that the rejection was unjustified and amounted to deficiency in service, particularly as no pre-policy medical examination was conducted despite her being a senior citizen. Despite paying all premiums and submitting documents for her breast cancer claim, she faced repeated delays and repudiation. Frustrated, she filed a consumer complaint on Nov 18, 2024, seeking reimbursement of medical expenses.In its defence, Star Health and Allied Insurance Company alleged that Manjula had suppressed material facts by disclosing only diabetes and hypertension, while failing to reveal a serious pre-existing cardiac condition. It relied on medical records, including a discharge summary from Apollo Hospital, to state that she was hospitalised and had a known case of inferior wall myocardial infarction, having undergone PTCA/angioplasty in Jan 2021, along with conditions such as ischaemic heart disease and obesity. The insurer argued that such non-disclosure of a life-threatening ailment prior to policy inception amounted to material misrepresentation.Maintaining that the claim was rightly repudiated, the company said the subsequent action to cancel the policy was valid.However, after going through all the documents and hearing both sides, the commission observed that the prior cardiac condition had no nexus with the breast cancer treatment and that no medical tests were conducted before issuing the policy, despite the complainant being a senior citizen. It concluded that the repudiation of claim amounted to deficiency in service.On March 5, 2026, the consumer forum ordered the insurance company to restore the policy and pay Rs 4.5 lakh with 9% interest, aside from paying Rs 20,000 for mental agony and Rs 10,000 as litigation costs.
