The district consumer disputes redressal commission in Chennai (North) has directed Star Health and Allied Insurance Company Ltd to pay ₹9.27 lakh along with interest to a Chennai woman for wrongfully denying her husband's cancer treatment claim on contradictory grounds. The commission also criticized the insurer for deficiency in service.
Commission's Observations
The bench, comprising President D Gopinath and members Kavitha Kannan and T R Sivakumar, emphasized that decisions regarding appropriate medical treatment should be made by treating doctors, not insurance companies. It ordered the insurer to pay ₹25,000 as compensation for deficiency in service and ₹5,000 towards litigation costs.
Background of the Case
The complaint was filed by Purna S Kamdar of Kilpauk three years ago after her husband, Sandip Kamdar, underwent treatment for cancer at the base of the tongue at Apollo Proton Cancer Centre in Chennai between February and March 2023. Kamdar was covered under a Star Super Surplus Health Insurance policy with a sum insured of ₹1 crore. He incurred medical expenses of nearly ₹31.8 lakh for the treatment.
Denial of Claim
According to the complaint, the insurer initially denied cashless treatment, stating that proton therapy was not medically necessary. Later, when reimbursement was sought, the company rejected the claim on a different ground, citing that the treatment was experimental or unproven under an exclusion clause in the policy. The complainant argued that proton therapy is a globally accepted and evidence-based treatment, particularly for head and neck cancers, and that the claim was denied despite recommendations from treating doctors.
Insurer's Defense
During the proceedings, Star Health contended that the dispute had already been settled before the Insurance Ombudsman, following which ₹10 lakh was paid to the insured. The insurer maintained that the settlement was reached with the complainant's consent, as per the order.
Commission's Ruling
The consumer commission noted that the insurer had taken contradictory positions while rejecting the claim and failed to provide sufficient evidence to support either reason. The commission further held that the partial settlement before the Ombudsman did not prevent the complainant from seeking relief under consumer law. Concluding that there was a clear deficiency in service, it directed the insurer to pay the remaining claim amount of ₹9.27 lakh with 9% annual interest from April 19, 2024, until payment is made.
