In an order, the commission observed that the insurer had taken inconsistent positions while denying coverage for Proton Therapy undergone by the insured patient for tongue cancer treatment at a Chennai hospital.

The bench, comprising President D Gopinath and members Kavitha Kannan and TR Sivakumhar, said the insurer initially denied cashless treatment approval stating that Proton Therapy was clinically not indicated for the illness. However, while rejecting the reimbursement claim later, the company termed the same treatment experimental and untested.

“The rejection of cashless claim and the repudiation of the reimbursement on different grounds for the same cause of action is found to be unfair and unjustified,” the commission said.

The complaint was filed by Purna S Kamdar, whose husband Sandip Kamdar underwent treatment for cancer of the tongue at Apollo Proton Cancer Centre in Chennai in 2023. The complainant argued that Proton Therapy was recommended by a team of specialists and was a globally accepted, evidence-based treatment for head and neck cancers.

The insurer contended that the claim had already been settled before the Insurance Ombudsman after a compromise under which Rs 10 lakh was paid against the total claim amount of Rs 31.8 lakh. It also claimed that the complainant had consented to the settlement through email communication.

The commission, however, noted that the insurer had failed to produce records establishing that the amount paid constituted a full and final settlement. It further observed that the treating doctor alone was competent to decide the course of treatment and an insurance company could not reject a claim by substituting medical opinion with its own interpretation.