Jalandhar: District consumer panel pulls up insurer for denying medical claim

The complaint was filed by Kewal Krishan, a resident of Ram Sharnam Colony in Jalandhar. Krishan had purchased a health insurance policy worth Rs 2 lakh covering himself and his wife, Rekha, in October 2018. The policy was valid until 2019. However, when Rekha was hospitalised during the policy period, the insurer initially denied a request for cashless treatment and later rejected a reimbursement claim of Rs 1.60 lakh.

The company contended that Rekha had been suffering from hypertension for two to three years before the policy was purchased but had failed to disclose the condition while taking the policy.

While examining the insurer’s justification for rejecting the claim, the commission noted that the company had failed to produce any previous prescription for anti-hypertensive medication or consultation records to establish that Rekha had been receiving treatment for hypertension before the policy commenced or had deliberately concealed the condition.

The commission also observed that hypertension was not listed among the ailments for which Rekha was treated, according to her discharge summary.

Holding that the insurer had failed to establish intentional suppression of a pre-existing condition, the commission directed the company to comply with the order within 45 days of receiving a copy of it.