Archive · 24 Jul 2026
Court rules in favor of policyholder against insurance claim rejection
A woman named Shivani Tomar had health insurance with Oriental Insurance.
She got sick and went to the hospital, where doctors said she needed to stay.
The insurance company said they wouldn't pay for her treatment because they thought she didn't really need to stay in the hospital.
But the court said the insurance company was wrong because they didn't have any proof to say that.
The court made the insurance company pay her back the money she spent on her treatment.
Shivani Tomar was hospitalized in November 2023 for chest heaviness, breathlessness, and other symptoms.
Oriental Insurance rejected her claim, stating hospitalisation was for diagnostic purposes only.
Tomar underwent multiple procedures and was diagnosed with severe acute gastritis, hypothyroidism, and an ovarian cyst.
The consumer commission ruled in Tomar's favor, stating the insurance company failed to provide medical evidence.
The commission directed Oriental Insurance to pay over ₹2.24 lakh to Tomar.
- Who
- Shivani Tomar, a policyholder of Oriental Insurance Company Ltd.
- What
- A health insurance claim rejection was overturned by a Delhi consumer commission.
- When
- The incident occurred in November 2023, and the court ruling was recent.
- Where
- The case was heard by the District Consumer Disputes Redressal Commission in Delhi.
- Why
- The insurance company rejected the claim stating that the hospitalisation was not medically necessary, but the court ruled in favor of the policyholder due to lack of evidence from the insurer.
Policyholder's Perspective
Insurance Company's Perspective
Medical Necessity of Hospitalisation
Policyholder's Perspective
The policyholder underwent several procedures and was diagnosed with severe acute gastritis, hypothyroidism, and an ovarian cyst, making hospitalisation medically necessary.
Insurance Company's Perspective
The insurance company argued that the policyholder's vital parameters and investigation reports were normal, and the admission was only for observation and diagnostic evaluation.
Application of Exclusion Clause
Policyholder's Perspective
The policyholder contended that the exclusion clause should not apply as the hospitalisation was not solely for diagnostic purposes but involved active treatment.
Insurance Company's Perspective
The insurance company relied on a policy clause excluding expenses where hospitalisation is primarily for diagnostic purposes.
- Policyholder
- Shivani Tomar
- Insurance Company
- Oriental Insurance Company Ltd.
- Hospital
- Max Healthcare Hospital, Vaishali
- Claim Amount
- ₹2,24,000
- Treatment Cost
- ₹1,54,144
- Diagnoses
- Severe acute gastritis, hypothyroidism, ovarian cyst
- Procedures
- Biopsy, endoscopy, MRI, ultrasound, intravenous fluids, antibiotics