While dismissing a revision petition filed by Niva Bupa Health Insurance Company Ltd, the national consumer disputes redressal commission (NCDRC) upheld a Karnataka state consumer commission order directing the insurer to pay more than Rs9.2 lakh in pending medical claims, along with Rs82,000 in additional compensation and interest, to Vishnu Deo Dubey, a 78-year-old Bengaluru-based policyholder.
The order, passed by a bench comprising Dr Inder Jit Singh (presiding member), and Dr justice Sudhir Kumar Jain (member), held that both the district and state commissions had delivered 'well-reasoned, concurrent findings' against the insurer, formerly known as Max Bupa Health Insurance Company. It found no reason to interfere with the state commission’s conclusions that the insurer was guilty of deficiency in service and unfair trade practice.
In 2014, Mr Dubey, a resident of Bellandur in Bengaluru, had purchased a joint health insurance policy from Niva Bupa for himself and his wife, Veena Dubey, with a sum insured of Rs32 lakh. After renewing the policy for a second year by paying Rs2.08 lakh, he was hospitalised several times between March and May 2016 at Apollo Hospital, Sakra Hospital and Manipal Hospital for treatment related to a urological condition. He submitted claims amounting to Rs14.02 lakh along with all relevant medical documents.
The insurer, however, repudiated his claim on the ground that he had failed to disclose a pre-existing medical condition. Niva Bupa alleged that Mr Dubey had been suffering from lower urinary tract symptoms for more than two years before the inception of the policy and that he had suppressed this information. Following the rejection of his claim, the insurer also cancelled his policy in March 2016, citing non-disclosure.
The decision was based on a case sheet from Apollo Hospital that incorrectly recorded that Dubey had experienced symptoms for 'two and a half years' instead of 'two and half weeks'. The treating doctor later confirmed that this was an error and the actual duration of illness was only a few weeks prior to hospitalisation. Despite this clarification, the insurer declined to reconsider its decision.
Mr Dubey approached the insurance ombudsman which dismissed his complaint in July 2017. With no relief, he filed a complaint before the additional district consumer forum II in Bengaluru, alleging wrongful repudiation of his claim, unjust cancellation of his policy and mental agony caused by the company’s actions.
The district forum found that the insurer had acted unfairly and directed it to pay Rs4.81 lakh towards the claim. Dissatisfied with the quantum, Mr Dubey appealed before the Karnataka state consumer commission, which enhanced the compensation to Rs9.20 lakh with 6% annual interest from August 2016. The state commission also ordered the insurer to pay Rs32,000 for loyalty coupon benefits that had been withheld and Rs50,000 as compensation for mental agony and litigation expenses.
Niva Bupa challenged the state commission’s ruling before NCDRC, arguing that the contract of insurance had already been terminated and that there was no obligation to pay any claim. The company also claimed that the award of loyalty benefits was contrary to the policy terms and that the lower forums had erred in interpreting the non-disclosure clause. The insurer cited several Supreme Court judgments in support of its contention that failure to disclose pre-existing diseases constitutes a valid reason for repudiation.
NCDRC, however, rejected these arguments, holding that the insurer’s unilateral cancellation of the policy and refusal to honour the claim were unjustified. The commission observed that both the district and state commissions had evaluated all medical records, including the correction made by Apollo Hospital which clarified that there was no deliberate suppression of information. It held that Niva Bupa had ignored this crucial evidence and instead acted in an arbitrary and unfair manner.
“The state commission has passed a well-reasoned order, and we do not find any reason to interfere with its findings,” the bench said in its order dated 3 October 2025. It concluded that the insurer’s actions caused undue distress to an elderly policyholder who had complied with all terms of his policy and that the cancellation of coverage amounted to a serious deficiency in service.
The commission further upheld the award of the Rs32,000 loyalty coupon benefit, stating that Niva Bupa had no valid reason to deny it since Mr Dubey had made no claim during the previous policy period.
With the dismissal of the insurer’s revision petition, NCDRC directed Niva Bupa to comply with the state commission’s order within two months of receiving the judgement. The insurer is required to pay Rs920,827 towards the pending medical claim with 6% annual interest from 4 August 2016, Rs32,000 towards loyalty coupons and Rs50,000 as compensation and litigation costs.
The commission’s ruling reinforces the principle that insurers must act fairly and reasonably, particularly in cases involving senior citizens. It also underscores that repudiation of a claim without proper evaluation of medical evidence or consideration of clarifications amounts to an unfair trade practice. By upholding the Karnataka state commission’s order, NCDRC has once again stressed the duty of insurers to deal in good faith with policyholders, especially when the repudiation of claims could have grave financial and emotional consequences for elderly citizens.
(Revision Petition No266 of 2025 Date: 3 October 2025)
