Insurer rejects claim over ‘history of high BP’, Himachal man wins Rs 2 lakh payout

The Himachal Pradesh State Consumer Disputes Redressal Commission has ruled in favor of a health insurance claim, awarding Rs 1.47 lakh, Rs 50,000 in compensation, and Rs 12,000 in litigation costs to a policyholder whose insurer had previously rejected the claim due to an alleged four-year history of hypertension. The commission found that the insurer did not provide sufficient medical evidence to prove that the condition existed prior to the policyholder purchasing the insurance.

The case originated when the policyholder, Mr. Kumar, suffered chest pain and was admitted to Amandeep Hospital in Pathankot on February 9, 2024, where doctors diagnosed him with a heart problem and advised immediate surgery. Despite paying the hospital bills totaling Rs 1,47,891 before submitting his claim to the insurer, Mr. Kumar was denied coverage.

The insurer argued that Mr. Kumar had concealed his hypertension for four years and violated the policy terms, but the commission held that the burden of proof was on the insurance company to provide clear and convincing medical evidence supporting the alleged pre-existing condition. The commission found no such evidence in the record and ruled in favor of Mr. Kumar's entitlement to the claimed amount, rejecting the insurer's claim that the Rs 50,000 compensation was excessive.