AHMEDABAD: After years of dispute over a rejected mediclaim, a city consumer forum in Ahmedabad ruled that an insurer had failed to substantiate its allegation of a pre-existing disease, ordering payment of the insured amount with interest and compensation.
A Dispute That Began With a Rejection
The case centres on a mediclaim policy issued by The Oriental Insurance Company Limited to Vanna Mahadevia, a resident of Ahmedabad. The policy, with a sum insured of ₹5 lakh, covered the period from April 4, 2018, to April 3, 2019, and was a renewal of an earlier health insurance cover.
During the policy period, Mahadevia’s husband, Anil Mahadevia, was hospitalised on three occasions between December 2018 and January 2019. The admissions, according to the complaint, were prompted by different medical issues over a short span of time, leading to cumulative expenses that exceeded the policy’s coverage.
Despite the policy being in force and the claim limited to the insured amount, the insurer rejected all three claims, triggering a dispute that would stretch across several years.
Certified Cyber Crime Investigator Course Launched by Centre for Police Technology
Hospitalisations and the Insurance Claim
Records placed before the consumer forum showed that Anil Mahadevia was first admitted in December 2018 with complaints of palpitations and a general sense of uneasiness. He was later hospitalised again in January 2019, this time for cough and other urological issues. Across the three admissions, the total medical expenditure amounted to ₹5.65 lakh.
Vanna Mahadevia restricted her claim to ₹5 lakh, corresponding to the sum insured under the policy. The insurer, however, denied the claim in full, asserting that Anil Mahadevia was suffering from hypertension, which it categorised as a pre-existing disease that had not been disclosed at the time of purchasing the policy. On this basis, the insurer maintained that it was entitled to repudiate the claim under the policy terms.
The Pre-Existing Disease Argument
The insurer’s position was contested by the complainant, represented by advocate Shrijit Pillai. Before the forum, Pillai argued that none of the hospital admissions had any medical connection to hypertension. He submitted that there was no material on record to show that hypertension had any relevance to the ailments for which Anil Mahadevia was treated.
The complainant also disputed the allegation of non-disclosure, contending that there was no evidence to establish that any pre-existing condition had been suppressed at the time of taking the policy.
The commission examined the insurer’s defence and noted the absence of medical evidence or expert opinion linking hypertension to the treatments undergone during the hospitalisations. It observed that the insurer had failed to prove both the existence of a pre-existing disease and its relevance to the medical treatment claimed.
The Forum’s Order and Its Aftermath
Allowing the complaint in part, the consumer forum directed The Oriental Insurance Company Limited to pay ₹5 lakh towards the mediclaim. The amount is to carry interest at the rate of 7 per cent per annum from April 4, 2022. In addition, the forum awarded ₹2,000 each towards compensation for mental agony and litigation costs.
The insurer has been directed to comply with the order within 45 days. The case had its origins in 2019, when the Consumer Education and Research Centre (CERC), Ahmedabad, initially took up the matter and attempted to resolve it through conciliation. When those efforts failed despite notices issued to the insurer, the dispute proceeded before the consumer forum, culminating in the recent order.
