Kochi | November 10, 2025 —
A consumer court in Kerala has taken a strong stand against arbitrary insurance claim rejections, holding Future Generali India Insurance Company Ltd. and its health division jointly liable for denying a legitimate claim.
The District Consumer Disputes Redressal Commission, Ernakulam — led by President D.B. Binu and members V. Ramachandran and Sreevidhia T.N. — ordered the insurer to pay the remaining hospital bill along with ₹30,000 in compensation and costs to the aggrieved policyholder.
The complainant, insured under a group medical policy worth ₹5 lakh, was hospitalized for bulbar urethral stricture and related conditions. After undergoing visual internal urethrotomy (VIU), his hospital bill amounted to ₹71,553. However, the insurer approved only ₹35,000, citing a “sub-limit” for urinary stone removal — a procedure the patient had not undergone.
An Unfounded Sub-Limit and a Deficient Service
While the insurer argued that the treatment was related to a urinary calculus (stone) and therefore subject to a policy cap, the Commission found this reasoning “factually incorrect and medically unsustainable.”
Citing the contra proferentem principle — which dictates that ambiguous policy terms must be interpreted against the insurer — the bench observed:
“The Opposite Parties’ application of a urinary-stone sublimit to a stricture-relieving VIU is arbitrary, medically unsustainable, and contractually unfounded. The plea of strict construction is unavailable where the clause is misapplied to a procedure it does not cover.”
The Commission concluded that the insurer’s conduct constituted both deficiency in service and unfair trade practice, noting that the complainant had produced ample medical evidence confirming the correct nature of the surgery.
‘Insurance Should Protect, Not Punish’
In a pointed observation that has resonated widely, the forum underscored the human cost behind bureaucratic denial:
“An insurance policy is meant to be a safety net in those anxious hours — not another hurdle.”
It criticized the insurer for disregarding the discharge summary and doctor’s certificate, instead “cherry-picking an incidental reference to calculus” to reduce payout.
Quoting a Kerala High Court precedent in Dr. A.M. Muraleedharan v. LIC, the forum reaffirmed that denial of medical insurance can violate the right to life under Article 21 of the Constitution.
A Signal for Humane Claim Handling
Ordering payment of the withheld balance and additional compensation, the Commission emphasized that claim processing must align with both medical accuracy and humane consideration.
“Consumer protection is, at its heart, about restoring fairness,” the order read. “Our decision aims to signal that claim assessment must be accurate, humane, and faithful to the medical evidence.”
The ruling adds to a growing chorus of judicial and consumer body pronouncements across India urging insurers to interpret policies liberally, especially in cases of genuine medical need.
