Chennai: The district consumer disputes redressal commission, Chennai (North) has ordered Star Health and Allied Insurance Company Ltd to pay ₹9.27 lakh with interest to a Chennai woman for denying the claim for her husband’s cancer treatment on contradictory grounds. It also pulled up the insurer for deficiency in service.The comprising President D Gopinath and members Kavitha Kannan and T R Sivakumar, observed that decisions on the appropriate course of treatment should be made by treating doctors and not insurance companies. It also ordered the insurer to pay ₹25,000 as compensation for deficiency in service and ₹5,000 towards litigation costs.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, who was covered under a Star Super Surplus Health Insurance policy with a sum insured of ₹ 1 crore, incurred medical expenses of nearly ₹31.8 lakh for the treatment.According to the complaint, the insurer first denied cashless treatment, stating that proton therapy was not medically necessary for the condition. Later, when reimbursement was sought, the company rejected the claim on a different ground, saying 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 the treating doctors.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, the order noted.However, the consumer commission noted that the insurer had taken contradictory positions while rejecting the claim and had 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.
