Insurer fails to prove ‘pre-existing’ breast cancer, policyholder gets Rs 1.3 lakh payout

4 min readNew DelhiJul 9, 2026 10:28 AM IST

The insurer said the complainant had hidden key facts while purchasing the policy. It added that the patient had a history of breast carcinoma as indicated by a 2021 ultrasound report. (AI-generated image)

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.

The 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.

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When 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 claim

The 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.

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Reimbursement ordered

The 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.

Allowing 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 takeaway

The 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.

Somya Panwar works with the Legal Desk at The Indian Express, where she covers the various High Courts across the country and the Supreme Court of India. Her writing is driven by a deep interest in how law influences society, particularly in areas of gender, feminism, and women’s rights.

She is especially drawn to stories that examine questions of equality, autonomy, and social justice through the lens of the courts. Her work aims to make complex legal developments accessible, contextual, and relevant to everyday readers, with a focus on explaining what court decisions mean beyond legal jargon and how they shape public life.

Alongside reporting, she manages the social media presence for Indian Express Legal, where she designs and curates posts using her understanding of digital trends, audience behaviour, and visual communication. Combining legal insight with strategic content design, she works on building engagement and expanding the desk’s digital reach.

Somya holds a B.A. LL.B and a Master’s degree in Journalism. Before moving fully into media, she gained experience in litigation and briefly worked in corporate, giving her reporting a strong foundation. ... Read More

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breast cancer

consumer court

health insurance