Insurer’s ‘pre-existing disease’ defence fails, policyholder gets relief in Rohtak
Rohtak consumer panel orders insurer to pay Rs 4.11 Lakh to policyholder for heart surgery claim
Holding that a genuine mediclaim was wrongly repudiated, the District Consumer Disputes Redressal Commission, Rohtak, headed by President Nagender Singh Kadian has directed an Insurance Company to reimburse more than Rs 4.11 lakh to a policyholder who underwent bypass heart surgery, along with interest and compensation.
The complaint was filed by Ashok Kumar of Sangahera village, who had purchased an Insurance Policy with a sum insured of Rs 5 lakh after paying a premium of Rs 27,895. The policy was valid from April 11, 2024, to April 10, 2025.
According to the complaint, Ashok developed chest pain in August 2024 and was initially examined before being referred to a cardiologist. He was later admitted to a private hospital in Delhi where he underwent coronary artery bypass grafting (CABG) surgery on August 17, 2024. He remained hospitalised from August 14 to August 22 and incurred medical expenses of over Rs 4.11 lakh.
However, the insurance company rejected his reimbursement claim, contending that medical records indicated he had been suffering from a chronic and long-standing heart disease prior to obtaining the policy and that the ailment fell under the category of a pre-existing disease, which was excluded from coverage during the initial waiting period.
During the proceedings, the Commission examined a clarification issued by a treating doctor at PGIMS, Rohtak, who admitted that a reference in the discharge summary to chest pain for the last three months was a mistake caused by a misunderstanding of a local Haryanvi expression. The doctor clarified that the patient had actually been suffering from chest pain for only three days before admission.
The Commission also noted that records from Delhi based private hospital and the insurer’s own vigilance verification report supported the complainant’s stand that the symptoms had surfaced only shortly before hospitalisation. It observed that the insurer had failed to produce any previous treatment records, prescriptions or investigation reports proving that the disease existed before the policy was purchased.
Concluding that the insurer had failed to establish the existence of a pre-existing disease, the Commission held that the claim was wrongly repudiated and that the action amounted to deficiency in service and unfair trade practice.
The Commission ordered the insurer to pay Rs 4,11,724 towards medical expenses with 9 percent annual interest from February 10, 2025, besides Rs 5,000 as compensation for mental harassment and Rs 5,000 towards litigation expenses.
