After facing a storm of criticism online over allegations of denying a Rs 61.6 lakh cashless claim, Niva Bupa Health Insurance has issued a detailed statement defending its position. The insurer said it had not rejected the claim, but only capped its pre-authorisation approval at Rs 25 lakh as the hospital's costs escalated far beyond the originally agreed package.
The case involves a patient, Mr Jain, who is undergoing treatment for Myeloid Leukaemia at Sir HN Reliance Foundation Hospital in Mumbai. The patient's family had alleged that despite a cover of Rs 2.4 crore, the insurer backed out when hospital bills climbed to over Rs 61 lakh, forcing them to arrange money themselves.
In its statement, Niva Bupa said Mr. Jain had been their policyholder since 2021 and had already made three claims this year. The company said that two earlier claims amounting to Rs 22.7 lakh were paid in full.
For the current hospitalisation, which began on June 27, 2025, the insurer pre-approved a Rs 25 lakh cashless claim for a bone marrow transplant, after discussions with the hospital. It also cleared an additional Rs 77,000 request on July 9.
However, the insurer said the hospital subsequently sought to raise the pre-authorisation from Rs 25 lakh to Rs 61 lakh, citing escalating costs, a figure that has since swelled to around Rs 80 lakh.
"Since this additional amount is significantly higher than the original estimate, the subsequent pre-authorisation request was not approved, and questions have been raised with the hospital," the company said.
Niva Bupa emphasised that this does not mean the claim has been denied. The approved Rs 25 lakh pre-authorisation remains valid, and the final claim amount will only be assessed at the time of discharge, once the hospital shares the discharge summary. The insurer also said it had requested the hospital not to seek further payments from the patient's family until cost justifications are provided.
Responding to criticism that labelled the industry a "scam," the company called such remarks "irresponsible and misleading." It stressed that Mr. Jain had already benefited from previous payouts and reiterated its commitment to honouring genuine claims.
This case raises bigger questions about rising hospital costs, pre-authorisation regulations by insurers, and the gap between patient expectations and insurer processes.
Claim denials and patient grievances have been growing, and this is becoming an issue that regulators may need to examine more closely.
