Insurer told to pay ₹5L to Chandigarh man over rejected claim

The insurance company argued that the claimant had hidden important medical information while purchasing the policy and was therefore not entitled to the claim

The state consumer disputes redressal commission has dismissed an appeal filed by Aditya Birla Capital Health Insurance Company against an order directing it to pay around ₹5 lakhs to a UT resident for medical expenses. The commission held that the insurer had failed to prove that the policyholder had hidden his previous medical condition while buying the insurance policy.

The commission held that the insurer had failed to prove that the policyholder had hidden his previous medical condition while buying the insurance policy. (HT File)

The complainant, Sourav Kapoor, had purchased a health insurance policy worth ₹20 lakh in April 2021. In August 2023, he was admitted to PGIMER, Chandigarh, for treatment of a brain lesion and incurred expenses of around ₹2 lakh. However, the insurance company rejected his claim, saying he had not disclosed a history of seizures and a brain lesion dating back to 2012.

Kapoor later underwent further treatment at Max Super Speciality Hospital, Mohali, between September 13 and October 24, 2023, spending another ₹3 lakh. The insurer rejected his request for cashless treatment and subsequently cancelled his policy, citing his medical history.

The insurance company argued that Kapoor had hidden important medical information while purchasing the policy and was therefore not entitled to the claim.

However, the commission observed that the medical condition cited by the insurer dated back to 2012, more than eight years before the policy began. Under the policy terms, a pre-existing disease was one diagnosed within 48 months before the start of the policy.

The commission also noted that medical records showed Kapoor had remained symptom-free until 2023. There was no clear medical evidence to establish that his condition in 2023 was linked to the medical history from 2012.

It further observed that the insurer had continued renewing the policy and accepting premiums before cancelling it on the basis of the old medical history.

Upholding the district consumer commission’s April 1, 2026, order, the state commission directed the insurer to pay ₹5,18,589 with 9% annual interest, ₹20,000 as compensation for mental harassment and ₹10,000 as litigation costs. It also upheld the direction to restore or renew the policy on the same terms and conditions.

The order was passed by presiding member Padma Pandey and member Rajesh K Arya on October 27. The appeal was dismissed with no order as to costs.