A Punjab consumer commission has directed a private insurance company to pay ₹1.81 lakh to a 76-year-old policyholder whose reimbursement claim for bilateral knee replacement surgery was rejected on the ground that his ailment was a pre-existing condition that had allegedly not been disclosed.
The District Consumer Disputes Redressal Commission, Moga, held that the insurer had failed to produce any medical record showing that the complainant had been diagnosed with or treated for the knee condition before taking the policy.
The bench comprising President Aparana Kundi and members Mohinder Singh Brar and Priti Malhotra also awarded ₹8,000 as compensation for the harassment caused to the senior citizen, along with litigation expenses.
No Medical Record Proving Prior Diagnosis
The insurer had relied on X-ray findings describing the knee ailment as chronic or longstanding to reject the claim. In its September 1 order, however, the commission held that such an assessment by itself was insufficient to establish that the condition had existed before the policy commenced or that the insured had deliberately concealed it.
The commission observed that the insurance company had not produced any earlier prescription, diagnostic report, medical record or document relating to previous treatment of the complainant for the condition.
It held that repudiation of the claim merely on the basis of an X-ray opinion describing the disease as chronic or longstanding could not be sustained without supporting medical evidence.
Knee Replacement Surgery Cost ₹2.63 Lakh
The complainant, a 76-year-old resident of Moga, was covered under the insurer’s Senior Citizen Red Carpet Health Insurance Policy.
He visited Sud Hospital, Jalandhar, on November 24, 2024, after experiencing problems in both knees and was advised to undergo surgery. He was admitted to the hospital on December 12 and underwent replacement of both knees the following day. He was discharged on December 17.
According to the complaint, he incurred medical expenses of ₹2.63 lakh and subsequently sought reimbursement from the insurer.
The company rejected the claim after relying on its medical assessment and X-ray findings, which, according to it, showed that the knee condition was chronic and had existed before the policy began.
The insurer alleged that the complainant had failed to disclose the condition while obtaining the policy and invoked the policy clause relating to non-disclosure of material facts.
Insurer Alleged Concealment of Health Condition
Before the consumer commission, the insurance company maintained that the complainant had concealed material information concerning his health and was therefore not entitled to reimbursement.
It submitted that the Senior Citizen Red Carpet policy covered only those pre-existing diseases that had specifically been disclosed by the proposer.
The insurer also relied on the policy’s 30 per cent co-payment clause and other conditions accepted by the complainant.
It further contended that the complaint raised complex questions that could not be decided in consumer proceedings and sought dismissal of the case.
The complainant had sought reimbursement of ₹2.63 lakh, ₹1 lakh as compensation for alleged mental harassment and deficiency in service, and ₹50,000 towards litigation expenses.
Waiting Period Had Already Expired
The commission noted that the policy had been renewed continuously and that the disputed claim arose during the third year of coverage.
It further found that the policy prescribed a 24-month waiting period for specified diseases and procedures and that this period had already expired when the claim arose.
The commission concluded that the treatment undertaken by the complainant was covered under the policy and that he was entitled to reimbursement of admissible medical expenses in accordance with its terms and conditions.
It consequently directed the insurer to pay ₹1.81 lakh towards the claim, besides ₹8,000 as compensation for the harassment caused to the senior citizen and litigation expenses.
