6 days ago
Himachal Commission Upholds Insurance Payout After Hypertension Dispute
A man in Himachal Pradesh bought health insurance for Rs 5 lakh.
While the policy was active, he was admitted to hospital with chest pain and needed heart treatment.
He paid hospital bills totaling Rs 1,47,891 and asked his insurer to reimburse him.
The insurer refused, saying he had high blood pressure for four years before buying the policy.
The insurer said he had not disclosed this condition.
The consumer commission said the insurer needed medical proof to support that claim.
It found that simply mentioning high blood pressure in the rejection letter was not enough.
The commission ordered the insurer to pay the treatment amount, compensation, and legal costs.
The state commission later upheld that decision.
The Himachal Pradesh State Consumer Commission upheld Rs 1,47,891 for a policyholder whose health claim was rejected.
The insurer alleged he had concealed a four-year history of hypertension before buying the policy.
The commission said the insurer provided no convincing medical evidence that hypertension predated the policy.
The policyholder’s February 2024 heart treatment generated bills of Rs 1,47,891, which he paid himself.
The ruling also upheld Rs 50,000 compensation and Rs 12,000 litigation costs, plus 9% interest on the claim amount.
- Who
- A Himachal Pradesh policyholder and his health insurer; the appeal was heard by the Himachal Pradesh State Consumer Disputes Redressal Commission.
- What
- The state commission upheld a health-insurance reimbursement of Rs 1,47,891, Rs 50,000 compensation, and Rs 12,000 litigation costs.
- Where
- The dispute was heard by consumer commissions in Himachal Pradesh; the medical treatment took place at Amandeep Hospital in Pathankot.
- When
- The policy ran from May 11, 2023, to May 11, 2024; the hospital admission occurred on February 9, 2024, and the state commission issued its ruling on August 25.
- Why
- The insurer rejected the claim alleging undisclosed, pre-existing hypertension, but the commissions found that it had not produced medical evidence proving the condition existed before the policy began.
Policyholder’s position
Insurer’s position
Whether hypertension was pre-existing
Policyholder’s position
The policyholder argued that the insurer had no medical evidence showing he had hypertension before obtaining the policy.
Insurer’s position
The insurer argued that he had suffered from hypertension for four years and had concealed it when buying the policy.
Validity of claim rejection
Policyholder’s position
The consumer commissions held that the claim rejection was unjustified because the alleged prior condition was not proved.
Insurer’s position
The insurer maintained that concealment of hypertension violated the policy terms and justified rejecting the claim.
Amount of compensation
Policyholder’s position
The policyholder defended the Rs 50,000 compensation while continuing to pursue the case.
Insurer’s position
The insurer argued that the compensation was excessive because it exceeded 35% of the awarded claim amount.
Key facts
- Policy sum insured
- Rs 5 lakh
- Policy period
- May 11, 2023, to May 11, 2024
- Hospital admission
- February 9-12, 2024
- Claim amount
- Rs 1,47,891
- Compensation
- Rs 50,000
- Litigation costs
- Rs 12,000
- Interest
- 9% per annum on the claim amount from the date of the complaint until realisation
Quotes
Himachal Pradesh State Consumer Disputes Redressal Commission
The state consumer commission bench hearing the insurer’s appeal.
“Mere mention of hypertension/BP in the repudiation letter, without any supporting medical evidence, does not establish that the complainant was suffering from the aforesaid disease prior to the commencement of the policy.”
indianexpress.com
“Therefore, the compensation of Rs 50,000/- awarded by the learned District Commission cannot be said to be excessive or disproportionate,”
indianexpress.com
Sources
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