A consumer forum in Himachal Pradesh has ordered Niva Bupa to pay a woman Rs 2.65 lakh after rejecting her claim for ovarian cyst surgery due to alleged waiting period violations, highlighting the importance of portability rules in health insurance.
A Himachal Pradesh consumer forum has ordered Niva Bupa Health Insurance Company Limited to pay a woman Rs 2.65 lakh after it rejected her reimbursement claim for ovarian cyst surgery on the grounds of a waiting period. The Kangra District Consumer Disputes Redressal Commission found that the insurer could not treat the condition as newly excluded when the policyholder had held uninterrupted health cover since 2019 and had later ported the policy with continuity benefits.
The dispute centred on whether the ovarian cyst could be linked to a previous gynaecological surgery and thereby brought within a 36-month exclusion for pre-existing disease. The woman had originally bought health cover from Star Health and Allied Insurance Company Limited in 2019, and the policy was later moved to Niva Bupa in 2022. According to the commission, the transfer preserved the waiting periods already served, which is consistent with IRDAI portability rules that allow policyholders to move insurers without losing accrued benefits.
In July 2024, she was diagnosed with an ovarian cyst and was admitted to hospital from August 13 to August 14, 2024, for surgery. Her medical bills came to Rs 2,30,124, including MRI costs. Niva Bupa rejected the claim in an August 23 email, saying the cyst was tied to an earlier hysterectomy and still fell within the policy’s exclusion clause. But the commission said the insurer could not restart a waiting period once continuity of cover had been maintained without interruption, especially after more than five years of insurance.
The commission said the rejection amounted to deficiency in service and unfair trade practice. It ordered the insurer to pay the claim amount with 9 per cent interest from the date the complaint was filed until payment, along with Rs 20,000 for mental agony and harassment and Rs 15,000 in litigation costs. The ruling underlines a broader point recognised in IRDAI guidance: when a health policy is ported without a break, the new insurer must carry forward completed waiting periods rather than treating the customer as though coverage had begun anew.
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