January 30, 2026 : In a detailed ruling reaffirming consumer rights in health insurance matters, the District Consumer Disputes Redressal Commission-II, U.T. Chandigarh has directed Max Bupa Health Insurance Company Ltd. to reimburse a maternity claim, holding that the insurer’s decision to repudiate the claim on the ground of incomplete disclosure of thalassemia minor was arbitrary and unsustainable.
The complaint was filed by Dilpreet Singh Gandhi, who had obtained a health insurance policy covering maternity benefits for the period 21 December 2018 to 20 December 2019. The policyholders had been continuously insured with the company since December 2015. During the subsistence of the policy, the complainant’s wife was admitted to Cloudnine Hospital, Chandigarh on 9 June 2019 for normal delivery. She delivered a baby girl on 10 June 2019 without complications and was discharged the following day. The total medical expenditure incurred for hospitalization and delivery amounted to ₹70,336.
A reimbursement claim of approximately ₹76,000 was submitted under the maternity benefit clause of the policy. However, the insurer repudiated the claim on 3 March 2020, citing incomplete medical history relating to thalassemia minor and invoking a policy clause dealing with non-disclosure and documentation requirements. According to the insurer, the complainant had failed to furnish relevant details regarding the duration and history of the condition.
Aggrieved by the rejection, the complainant approached the Consumer Commission alleging deficiency in service and unfair trade practice. The insurance company defended its action, contending that the claim was rightly rejected due to incomplete medical disclosure and non-submission of requisite documents. The hospital did not contest the proceedings and was proceeded against ex parte.
Upon examining the medical records, including the discharge summary, the Commission found that the purpose of admission was normal delivery and that the delivery was uncomplicated. While thalassemia minor was mentioned in the medical history, the Commission noted that it had no connection with the hospitalization or the delivery. There was no evidence to suggest that the condition contributed to or affected the insured event in any manner.
The Commission observed that repudiation of an insurance claim must be based on suppression of material facts that have a direct nexus with the claim. A medical condition that bears no causal link to the treatment for which reimbursement is sought cannot be treated as material for the purpose of denying liability. Denial of a legitimate claim on such technical or irrelevant grounds, the Commission held, amounts to deficiency in service.
While acknowledging that the complainant had incurred expenses exceeding ₹70,000, the Commission noted that the maternity benefit under the policy was capped at ₹35,000 per policy year. As the complainant had restricted his claim to that amount, the Commission partly allowed the complaint and directed the insurer to pay ₹35,000 along with interest at 9 percent per annum from 3 March 2020 until realization. Additionally, ₹20,000 was awarded towards compensation for harassment and litigation expenses. The insurer was directed to comply with the order within 60 days from receipt of the certified copy. The complaint against the hospital was dismissed as no deficiency in service was established against it.
The ruling reinforces the principle that disclosure obligations in insurance contracts must relate to facts material to the risk or claim. Mere reference to a pre-existing condition, without any demonstrable nexus to the insured event, cannot be used as a ground to defeat a valid maternity claim.
