A consumer body in Himachal Pradesh has directed Niva Bupa Health Insurance Company to reimburse Rs 80,439 to a policyholder after finding no evidence that his wife had concealed pre-existing cancer while purchasing the policy. It also awarded Rs 50,000 as compensation and litigation costs.A bench comprising president D R Thakur and members Vijay Lamba and Neelam Gupta of the Solan Consumer Dispute Redressal Commission observed that since the complainant’s wife is alive, she is entitled to reimbursement of the medical expenses incurred on her treatment and not the entire sum.“The complainant has not suppressed any material fact of the previous illness of his wife in the proposal form. Opposite party therefore has not proved this fact that there was previous illness…at the time of taking the insurance policy,” the June 20 order said.The bench noted that the insurance company had not examined any independent investigator to show that the complainant’s wife suffered from a pre-existing illness.On November 3, 2022, the complainant purchased a health insurance policy from Niva Bupa Health Insurance Company Ltd after paying a premium of Rs 17,970. The policy provided a sum insured of Rs 5 lakh and covered the complainant, his wife, and their two daughters until November 2, 2023.Also Read | ‘Ladies suits’ worth Rs 8,500 shrink after first wash, bridal boutique to pay Rs 35,500The complainant said his wife later developed pain and tenderness in her left breast and was taken to a hospital in Kharar. During the examination, the doctors found a small benign nodule and referred her to a higher centre for further evaluation.The complainant alleged that the insurance company denied providing cashless or other medical facilities even as the wife was diagnosed with breast cancer and underwent treatment at the Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh. The complainant claimed that he had to spend Rs 5 lakh on his own.Story continues below this adWhen he sought a reimbursement by submitting his claim to the insurance company, they rejected his request, allegedly on false and frivolous grounds.Policy promise vs past diagnosis claimThe complainant claimed his wife’s treatment was covered under the health insurance policy and the insurer had wrongly refused to honour the claim despite submitting all the required documents.The company contended that the complainant had suppressed crucial facts while purchasing the insurance. It submitted that the patient (complainant’s wife) had a history of carcinoma of the left breast as per the report of ultrasound of a diagnostic centre dated May 15, 2021.The company submitted that the complainant had no locus standi to file the complaint, as its consent to issue the insurance was obtained by fraud, and the insurance contract was voidable. It also claimed that the complainant wilfully suppressed his wife’s illness in the proposal form to avail undue insurance advantage and, therefore, the claim was rightly rejected.Story continues below this adReimbursement orderedThe commission observed that although the complainant had not placed the medical bills on record, the insurer had produced the bill along with the reimbursement claim.Also Read | ‘Impure’ diesel damages car’s injector, fuel station to pay owner Rs 54,000Allowing the complaint, the commission directed Niva Bupa Health Insurance Company to reimburse the complainant’s Rs 80,439 along with 9 per cent interest per annum from the date of filing of the complaint until realisation. It directed the insurance company to comply with the order within 30 days. The commission also awarded the complainant Rs 30,000 as compensation for mental agony and harassment and Rs 20,000 towards litigation costs.Consumer takeawayThe ruling reinforces that an insurance company is liable to pay the amount claimed by the consumer if it is within the policy period. If, despite multiple requests, it fails to pay the amount, the company would be held liable for deficiency in service. The consumer has the right to challenge the denial by producing relevant evidence.Aggrieved consumers may contact the consumer helpline in their respective states (Himachal Pradesh helpline: 1800-180-8087) or call the National Consumer Helpline at 1915 for assistance.