Max Bupa told to pay Rs 50 lakh heart attack cover after rejecting critical illness claim
The Punjab State Consumer Commission held that Max Bupa Health Insurance wrongly denied a critical illness claim for a first heart attack and ordered it to pay Rs 50 lakh with 6% interest.
Key points
- The Punjab State Consumer Disputes Redressal Commission held Max Bupa Health Insurance deficient in service for denying a critical illness claim.
- The insurer must pay the Rs 50 lakh claim with 6% interest from the date of rejection, plus Rs 1 lakh as compensation and litigation costs.
- The commission held that an insurer cannot add new reasons in court beyond the reason it gave when it rejected the claim.
The State Consumer Disputes Redressal Commission, Punjab, on 5 November 2026 ordered Max Bupa Health Insurance Co. Ltd. to pay a Rs 50 lakh critical illness claim for a policyholder's first heart attack, with 6% interest from the date the claim was rejected. The policyholder died while the case was pending, and his legal heirs carried it on.
What Happened
The policyholder bought a Criticare cover of Rs 50 lakh for 6 July 2018 to 5 July 2019, paying a premium of Rs 31,370. He was treated for a heart attack at two hospitals in Bhiwani and Rohtak in January 2019 and claimed the cover. The insurer marked the claim "denied", saying he did not meet the policy's critical illness criteria, according to the order.
The commission first dismissed the complaint in 2022 and sent the family to a civil court. The National Commission set that aside on 18 July 2025 and sent the case back for a fresh hearing.
This time the commission found that the hospital records, including the ECG and Troponin reports, carried the insurer's own "Claim Rejected" stamp, which showed they had been handed over. It noted the insurer had issued no formal rejection letter and had not produced the letter in which it said it had asked for documents. The commission held that the insurer, which raised a new objection about the records at the hearing, had failed to prove any fraud, and, citing the Supreme Court, that an insurer cannot go beyond the grounds in its rejection.
The insurer must pay Rs 50 lakh with 6% interest from the date of rejection and Rs 1 lakh as composite compensation and litigation costs. The order is the commission's finding and may be appealed.
What It Means
Policyholders with a rejected critical illness claim should keep copies of every record they hand to an insurer's investigator, and ask for the reason for rejection in writing. Complaints can be taken to the National Consumer Helpline (1915) or filed through e-Daakhil.
Source: Consumer commission order
Sources & Citations
- Consumer commission order — Consumer commission