A Mumbai consumer forum has mandated that health insurers cannot refuse claims solely based on waiting-period clauses without evidence that illnesses existed before policy coverage began, in a landmark case involving a ₹5 lakh pancreatitis claim.
A Mumbai consumer forum has ruled that health insurers cannot simply cite a waiting-period clause to refuse a claim unless they can show the illness was already present before cover began. The decision, reported by The Economic Times and other Indian publications, came in a dispute over a ₹5 lakh pancreatitis claim and directed Niva Bupa Health Insurance Co. Ltd., formerly Max Bupa, to settle the case.
The Mumbai Suburban District Consumer Disputes Redressal Commission said a waiting period is meant to stop people buying cover after a disease has already been diagnosed or symptoms have already appeared, then seeking payment for that condition. But the forum found that the insurer had not proved the policyholder had pancreatitis before the policy started in October 2017. The condition was diagnosed only in January 2019, after the cover had been renewed, and the commission said there was no evidence the illness pre-dated the policy.
According to the complaint, the policyholder was admitted after severe abdominal pain and was later found to have acute pancreatitis. He died on 7 February 2019 from acute pancreatitis and multiple organ failure. His family said hospital bills came to about ₹6.10 lakh across two hospitals, and that they paid the costs by borrowing from relatives after being told the policy included cashless treatment. Max Bupa rejected the two claims in March 2019, relying on a 24-month waiting period for pancreatitis.
The commission also pointed to the treating doctor’s view that the case was rare and had no apparent cause, which supported the finding that it arose unexpectedly during the policy term. The Free Press Journal reported that the forum held the insurer guilty of deficiency in service and unfair trade practice, and ordered payment of ₹5 lakh with 6% annual interest, along with ₹50,000 in compensation and ₹10,000 in litigation costs. The ruling is likely to be read as a warning that insurers must justify claim repudiations with evidence, not just policy wording.
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