5 min readNew DelhiAug 27, 2026 06:30 PM IST
The Himachal Pradesh State Consumer Disputes Redressal Commission has upheld the payment of Rs 1.47 lakh towards a health insurance claim, besides Rs 50,000 compensation and Rs 12,000 litigation costs for a policyholder whose claim was rejected by the insurer over an alleged four-year history of hypertension. The commission held that the insurer failed to produce medical evidence proving that the condition existed before he bought the policy.
President Justice Inder Singh Mehta and member Yogita Dutta were hearing an appeal filed by the insurance company against the February 11, 2025 order of the Kangra district consumer commission.
“Mere mention of hypertension/BP in the repudiation letter, without any supporting medical evidence, does not establish that the complainant was suffering from the aforesaid disease prior to the commencement of the policy,” the commission said on August 25.
The case arose after the complainant purchased a health insurance policy with a Rs 5 lakh sum insured, valid from May 11, 2023, to May 11, 2024. On February 9, 2024, while the policy was in force, he suffered chest pain and was admitted to Amandeep Hospital in Pathankot. Doctors diagnosed him with a heart problem and advised immediate surgery for placement of a balloon catheter in the heart. He was discharged on February 12, 2024.
Claim rejected over ‘hypertension’
The hospital issued bills of Rs 1,47,000 and Rs 891, which the man paid before submitting his claim to the insurer. However, the insurer rejected the claim by an email dated April 6, 2024, stating that Kumar had been suffering from hypertension or high blood pressure (BP) for four years and had failed to disclose the condition when purchasing the policy. The man then approached the consumer commission alleging deficiency in service.
The district commission allowed his complaint and directed the opposite parties to jointly and severally pay Rs 1,47,891, along with interest at 9 per cent per annum from the date of the complaint until realisation. It also awarded Rs 50,000 as compensation and Rs 12,000 towards litigation costs.
The insurance company appeared before the district commission but failed to file its reply within the stipulated 45-day period, and its right to file the reply was struck off. The company later failed to appear and was proceeded against ex parte (without hearing its side) by an order dated November 7, 2024.
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The insurer challenged the district commission’s decision before the state commission, arguing that the man had concealed his hypertension and violated the policy terms. It also challenged the Rs 50,000 compensation as excessive, arguing that it amounted to more than 35 per cent of the amount awarded towards the claim.
The complainant’s counsel opposed the appeal, submitting that there was no medical evidence on record to show that he had been suffering from the alleged disease before obtaining the policy.
Insurer fails to prove condition pre-existed
The state commission held that the burden was on the insurance company to prove that the man was suffering from the alleged disease before obtaining the policy and had deliberately suppressed the fact.
But the insurer failed to place on record any “cogent and convincing medical evidence” establishing that he had been suffering from hypertension for four years before the policy began. The commission also noted that the discharge slip issued by the concerned doctor did not disclose the alleged previous ailment.
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The commission further noted that the insurer had been proceeded against ex parte before the district commission and had failed to produce any document or medical evidence showing that the patient suffered from hypertension before obtaining the policy.
The bench, therefore, found nothing wrong in the district commission’s conclusion that the repudiation of the claim was not justified and held that the man was entitled to the claimed amount.
The state commission also rejected the insurer’s claim that the Rs 50,000 compensation was excessive, noting that the man filed his consumer complaint on May 23, 2024, and had continued pursuing the litigation. “Therefore, the compensation of Rs 50,000/- awarded by the learned District Commission cannot be said to be excessive or disproportionate,” the commission held.
Takeaway
For consumers, the ruling underscores that an insurance company cannot rely solely on an allegation of a pre-existing disease to reject a health insurance claim. Where an insurer alleges that a policyholder concealed an illness, it must support that allegation with clear and convincing medical evidence showing that the condition existed before the policy was obtained and was deliberately suppressed.
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Aggrieved consumers may contact the consumer helpline in their respective states (Himachal Pradesh: 1800-180-8087) or call the National Consumer Helpline at 1915 for assistance.
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