Surat: Surat District Consumer Disputes Redressal Commission (Additional) has ruled that an insurance company cannot repudiate a medical insurance claim by citing non-disclosure of a pre-existing condition unrelated to the ailment for which treatment was sought.The commission held that there was no connection between an ovarian tumour diagnosed in a woman and Kienbock disease, a wrist-related condition she had been suffering from since 2017. It observed that the insurer had failed to establish any link between the two ailments and had wrongly rejected her claim.The commission partly allowed a consumer complaint filed by the woman against Niva Bupa Health Insurance Company Ltd and directed the insurer to reimburse Rs 75,449 towards medical expenses, with 7% annual interest from Dec 19, 2023, until payment. It also ordered the company to pay Rs 3,000 as compensation for mental agony and harassment and Rs 2,000 towards litigation expenses.According to the complaint, the woman was covered under a health insurance policy purchased from the company for the period between June 26, 2023, and June 25, 2024. The policy carried a sum insured of Rs 3 lakh.On Oct 7, 2023, she complained of abdominal pain and was admitted to Ishaan Maternity Hospital in Surat. Following medical investigations, she was diagnosed with a right ovarian tumour and underwent treatment. She was subsequently discharged, with medical expenses totalling Rs 75,449.The woman and her husband subsequently submitted a reimbursement claim to the insurance company. However, the insurer rejected it through a letter dated Nov 24, 2023.The insurance company contended that the woman had been suffering from Kienbock disease since 2017 and had failed to disclose the pre-existing medical condition while purchasing the policy. It argued that the non-disclosure amounted to suppression of material information and violated the policy’s terms and conditions.Advocates Prachi Desai and Ishan Desai, appearing for the woman, argued that Kienbock disease had no connection with the ovarian tumour for which she had sought treatment. They maintained that the insurance company had unfairly rejected a genuine claim despite the medical expenses being covered under the policy.After examining the documentary evidence, medical records and submissions made by both sides, the commission observed that the insurer had failed to establish any connection between Kienbock disease and the right ovarian tumour.The commission noted that the ovarian tumour diagnosis was clearly mentioned in the hospital discharge summary. It held that merely having a pre-existing condition unrelated to the ailment for which treatment was claimed could not, in the circumstances of the case, justify repudiation of the insurance claim.Accordingly, the commission partly allowed the complaint and directed Niva Bupa Health Insurance Company to reimburse Rs 75,449 towards medical expenses, with 7% annual interest from Dec 19, 2023, until realisation.
