3 hrs ago
Punjab Commission Orders Insurer To Pay Denied Knee Claim
A 76-year-old man needed both knees replaced.
His health insurer refused to pay because an X-ray suggested his knee problem was old.
The insurer said he should have disclosed the problem before buying the policy.
The man said the insurer had not proved that he knew about an earlier diagnosis.
A consumer commission in Punjab agreed with the man.
It said an X-ray alone could not prove deliberate hiding of a disease.
The commission ordered payment of Rs 1.81 lakh, Rs 8,000 for harassment, and litigation expenses.
It also noted that the policy’s waiting period had already ended.
A Punjab consumer commission ordered an insurer to pay Rs 1.81 lakh to a 76-year-old Moga resident.
The man underwent replacement of both knees in December 2024 after treatment at Sud Hospital, Jalandhar.
The insurer rejected reimbursement, arguing that X-rays showed a chronic, pre-existing condition he had not disclosed.
The commission found no prior medical records proving diagnosis, knowledge, or deliberate non-disclosure of the condition.
The insurer was also ordered to pay Rs 8,000 for harassment and litigation expenses.
- Who
- A 76-year-old Moga resident, his private health insurer, and the District Consumer Disputes Redressal Commission, Moga.
- What
- The commission ordered the insurer to reimburse Rs 1.81 lakh, pay Rs 8,000 for harassment, and cover litigation expenses after rejecting the man’s knee-replacement claim.
- Where
- The case was decided in Moga, Punjab; treatment took place at Sud Hospital in Jalandhar.
- When
- The man underwent surgery on December 13, 2024; the commission issued its ruling on September 1, with no year specified in the article.
- Why
- The insurer alleged the knee condition was pre-existing and undisclosed, but the commission found no medical evidence proving prior diagnosis or deliberate non-disclosure.
Policyholder’s Position
Insurer’s Position
Whether the knee condition was pre-existing
Policyholder’s Position
The policyholder argued that the insurer had not produced records proving a prior diagnosis or treatment for the knee condition.
Insurer’s Position
The insurer argued that medical assessment and X-ray findings showed the condition was chronic and existed before the policy began.
Whether the condition was deliberately concealed
Policyholder’s Position
The policyholder maintained that an inference from an X-ray could not establish that he knowingly hid a disease.
Insurer’s Position
The insurer said the condition was not disclosed in the proposal form and therefore amounted to misrepresentation.
Coverage and waiting period
Policyholder’s Position
The policyholder sought reimbursement for the knee replacements, arguing that the treatment was covered.
Insurer’s Position
The insurer relied on policy terms, including coverage rules for declared pre-existing diseases and a 30 per cent co-payment clause.
Key facts
- Complainant
- 76-year-old resident of Moga
- Policy
- Senior Citizen Red Carpet Health Insurance Policy
- Treatment
- Both-knee replacement surgery on December 13, 2024
- Medical expenses
- Rs 2.63 lakh
- Amount ordered
- Rs 1.81 lakh in admissible medical expenses
- Additional compensation
- Rs 8,000 for harassment, plus litigation expenses
- Key finding
- An X-ray indicating a chronic condition alone did not prove deliberate non-disclosure
Quotes
District Consumer Disputes Redressal Commission, Moga
The Moga consumer commission bench that decided the insurance dispute.
“The repudiation of the claim merely on the basis of the X-ray opinion regarding the disease being chronic/longstanding cannot be sustained. Accordingly, the repudiation of the claim by the Opposite Party is held to be unjustified.”
indianexpress.com
“It is evident that treatment taken by the complainant for the disease in question falls under the policy in question, so the complainant is entitled to the claim in question.”
indianexpress.com
Sources
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