Heart disease insurance claim wrongly denied, man wins Rs 3 lakh consumer payout

The bench added that the Insurance companies, in their eagerness to sell insurance policies, often do not fully disclose all the terms and conditions of the policy to consumers, and instead, they highlight only the benefits of the policy.

Heart treatment claim wrongly rejected

The complainant, a 67-year-old resident of Korba, purchased a health insurance policy from Niva Bupa Health Insurance Co. Ltd. for the period December 21, 2024, to December 20, 2025, after paying an annual premium of Rs 41,004.

On October 5, 2024, he developed severe chest pain and vomiting and was admitted to the Indira Gandhi District Hospital, Korba. As the hospital lacked angiography facilities, doctors referred him to Gaurav Hospital, Bilaspur, where he underwent further investigations and angiography. He claimed to have spent nearly Rs 3 lakh on his treatment.

After treatment, he submitted a reimbursement claim to the insurer. However, Niva Bupa refused to settle the claim, stating that he had failed to furnish certain documents relating to his initial treatment at the district hospital and other medical records. The complainant contended that he had already submitted all available documents and that no additional records existed because he had remained at the district hospital for only one day before being referred.

Alleging that the insurer had arbitrarily rejected his genuine claim despite receiving the required documents, he served a legal notice and subsequently approached the District Consumer Commission, claiming reimbursement of his medical expenses along with compensation for mental agony, travel expenses, and litigation costs, alleging deficiency in service.

Mere technical grounds: Order

• The opposite party ought not to have repudiated the entire claim on mere technical grounds.
  The insurer had also sought investigation reports relating to the complainant’s chest pain/coronary artery disease before his hospitalisation.
• However, the complainant had already filed the discharge ticket issued by the District Hospital, which recorded that he had been admitted with chest pain. T
• Therefore, the commission found that the insurer’s insistence on investigation reports relating to treatment received before hospitalisation was unwarranted.
• The hospital had already recorded the details of the stent in its medical bills and discharge summary, which was sufficient. Production of the stent sticker was not mandatory.
• The documents placed on record in the case also clearly show that the complainant submitted all records relating to the treatment received at Gaurav Hospital, including the doctor’s examination reports and the discharge summary.
• In such circumstances, the insurer’s decision to reject the claim on the ground that consultation notes and certain treatment records were not furnished cannot be considered justified.
• The commission held that the insurer’s contention that the insurance claim was liable to be rejected merely based on the non-submission of documents was not acceptable.

• The opposite party ought not to have repudiated the entire claim on mere technical grounds.
• In the present case, the complainant had submitted the discharge summary, the doctor’s certificate, and other relevant documents.
• Therefore, rejecting the claim solely because the stent sticker or invoice used during the surgery was not produced amounts to a deficiency in service.

Significance of ruling

This ruling reinforces that health insurers cannot reject genuine medical claims on hyper-technical grounds when the treatment and expenses are otherwise established. It emphasises the consumer-centric purpose of health insurance, discourages arbitrary claim denials over minor documentation issues, and strengthens accountability of insurers for fair and reasonable claims settlement.

Consumers facing similar grievances may contact the consumer helpline in their respective states (Chhattisgarh helpline: 1800-233-3663) or dial the National Consumer Helpline at 1915 for assistance.