The dispute stemmed from a March 2023 road accident in which Saini and his wife were injured. After his wife died, the insurer rejected reimbursement claims over an alleged undisclosed pre-existing condition, but the commission found no nexus between it and the accident-related treatment.

According to the complaint, Saini had purchased a Family Floater Arogya Plus health insurance policy after paying a premium of Rs 21,835. The policy, carrying a sum insured of Rs 7.5 lakh, was valid from March 26, 2022, to March 25, 2023, and covered him, his wife Pinki Saini and other family members.

On March 4, 2023, the couple met with a road accident and suffered injuries. Saini was treated at Joshi Hospital, Jalandhar, while his wife, who was critically injured, was shifted to Dayanand Medical College and Hospital, Ludhiana, before undergoing further treatment at Satyam Hospital Trauma Care Centre, Jalandhar. According to the complaint, the family spent Rs 8,88,014 on her treatment before she succumbed to the injuries on May 15, 2023.

After the treatment, Saini submitted reimbursement claims for himself and his wife. However, the insurer rejected both claims and also cancelled the policy, alleging suppression of material facts.

‘History of hypertension, stroke’

The insurer argued that medical records showed Pinki Saini allegedly had a history of hypertension before the policy was purchased and that this had not been disclosed in the proposal form.

It also claimed she had suffered a cerebrovascular accident (stroke) before obtaining the insurance policy. According to the insurer, this alleged non-disclosure entitled it to reject the claims and cancel the policy.

Saini denied intentionally concealing any medical history and contended that the claims arose solely because of the injuries suffered in the road accident. He argued that even if the insurer’s allegations regarding hypertension were accepted, the condition had no connection with the treatment for which reimbursement was sought.

No link to accident: Forum

After examining the evidence, the commission held that the insurer failed to prove that the alleged hypertension had any link to the accident injuries or the treatment for which reimbursement was claimed.

It noted that the hospital records relating to the accident did not establish that hypertension contributed to the hospitalisation. The commission also found that the insurer had not produced sufficient evidence to prove fraudulent suppression of facts. It reiterated that in accident-related claims, rejection cannot be based just on an unrelated pre-existing ailment without establishing a direct connection to the claim.

Referring to earlier consumer forum decisions, the commission observed that common lifestyle conditions cannot automatically serve as grounds for denying insurance benefits when they have no bearing on the cause of treatment.

Partly allowing the complaint, the commission directed the insurer to reimburse Rs 8,88,014 with 6 per cent annual interest from the date the claim was lodged until its realisation. It also awarded Rs 20,000 as compensation for mental harassment and Rs 10,000 towards litigation expenses, directing compliance within 45 days.

The commission, however, did not grant all his prayers, including those relating to the cancellation and renewal of the health insurance policy.

Consumer takeaway

The order highlights that health insurers cannot reject accident-related claims merely by alleging a pre-existing illness. They must prove a direct link between the condition and the treatment, and consumers can challenge arbitrary claim rejections before consumer commissions.

For consumer-related grievances, individuals may contact the consumer helpline in their respective states and Union territories (Punjab: 0800-22577) or call the National Consumer Helpline at 1915 for assistance.