The District Consumer Disputes Redressal Commission, Mohali has directed Care Health Insurance Limited to reimburse a mediclaim of ₹3.72 lakh to a Mohali resident after finding the company deficient in service for rejecting the claim on grounds of a pre-existing disease.
The complaint was filed by Sandeep Singh, a resident of Mohali, whose father Narendra Singh underwent an emergency cardiac procedure at PGIMER, Chandigarh, in November 2021 after being diagnosed with coronary artery disease. The treatment involved stent placement at a cost ₹3,72,257.
Despite submitting all required documents, the insurance company repudiated the claim in February 2022, alleging that the patient had a 12-year history of hypertension that was not disclosed at the time of purchasing the policy.
During proceedings in Sandeep Singh vs Care Health Insurance Limited, the commission, comprising president SK Aggarwal and it’s members Paramjeet Kaur and Lt Col JS Bath examined medical records and policy documents and found that the insurer failed to produce convincing evidence to establish that the ailment existed prior to the policy or that there was any deliberate concealment of facts.
The commission observed that a mere mention of hypertension in hospital records was insufficient to deny a legitimate claim. It held that the insurer could not rely on vague medical entries to repudiate claims without substantiating them through proper evidence.
Holding the repudiation unjustified, the commission ruled that the insurer had acted deficiently in service and failed to honour its contractual obligation towards the policyholder.
Partly allowing the complaint, the commission directed the company to pay the claim amount of ₹3,72,257 within two months, failing which it will attract an interest of 6% per annum from the date of the order until realisation. It also awarded ₹25,000 to the complainant for mental agony, harassment, and litigation expenses.
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