Policy Cancelled Hypertension Insurer Restore Rs 1 10 Lakh

A Hyderabad consumer commission has held officials of Aditya Birla Health Insurance guilty of deficiency of service after finding that they allegedly wrongly rejected a senior citizen’s claim and cancelled the policy over alleged non-disclosure of hypertension. The commission directed them to reimburse the senior citizen’s hospitalisation expenses of Rs 93,000, reinstate his health insurance policy and pay Rs 15,000 as compensation.

Holding that the policy had been in force for over five years and that the officials failed to produce evidence supporting their stand, President Vakkanti Narasimha Rao and P V T R Jawahar Babu (member) allowed the 67-year-old’s complaint.

“As the treatment has been taken for hypertension during the subsistence of the policy, the complainant approached the opposite party ( Aditya Birla Health Insurance officials) for reimbursement of claim for the expenses incurred for treatment wherein the claim was rejected by the opposite parties without assigning any substantial reason for which acts upon their part is amounts to deficiency of service, that leads adoption of unfair practice,” the July 10 order read.

The man claimed that he took a family health insurance policy from Aditya Birla Health Insurance in September 2018 for himself and his wife and paid premiums regularly for the policy without any defaults, continuing till 2024. He was later hospitalised on December 13, 2023, at a hospital for chest pain and shortness of breath, wherein he was admitted and treated for three days by incurring hospitalisation expenses of Rs 93,000 when the said policy was in force.

However, his claim was allegedly rejected, and the policy was subsequently cancelled, alleging non-disclosure of hypertension.

The man claimed that he had disclosed his health details during the pre-policy medical check-up and that hypertension had been mentioned as a possible condition. He also claimed that he had disclosed his use of Stamlo 5 mg for a temporary high blood pressure issue.

He submitted that even if hypertension was treated as a pre-existing condition, the applicable cooling-off period had already expired by the time of his 2023 hospitalisation. The man was represented by advocate Sai Vamshi Vangipuram in the matter.

Noting that the said policy commenced from 2018 and the man underwent treatment in 2023, and the policy was in force up to 2024, the commission found that the officials of the insurance company had not even filed a “single piece of paper” to substantiate their claim of rejection, and found such unilateral acts are “highly objectionable”.

The commission also noted that the officials’ arguments that the complainant had been suffering from the condition since 2017 were not supported by substantial documentary evidence.

Accordingly, the commission directed the officials of the insurance company to pay the hospitalisation claim amount of Rs 93,000 jointly and severally and pay Rs 10,000 for the mental agony and Rs 5,000 towards costs and legal proceedings to the complainant.

The officials were also directed to reinstate the health insurance policy for the complainant, without assigning any cancellation as claimed, and to ensure that no further actions are taken to cancel the policy due to hypertension or any other reason, especially after the cooling-off period has passed.

The branch managers of insurance, represented by advocate G Nagesh, claimed that the complaint was false, frivolous and vexatious, neither maintainable in law nor on facts for which the same is liable to be dismissed with exemplary costs. It was submitted that the complainant had not approached this commission with clean hands and he has got no locus standi (place to stand) to file the present complaint.

The order highlights that an insurer cannot reject a claim or cancel a policy on allegations of non-disclosure without substantiating its stand with supporting evidence, particularly where the policy has remained in force for several years, and premiums have been regularly paid.

For consumer-related grievances, individuals may contact the consumer helpline in their respective states and union territories (Telangana: 1800-4250-0333) or call the National Consumer Helpline at 1915 for assistance.

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Richa Sahay is a Legal Correspondent for The Indian Express (Digital), where she focuses on simplifying the complexities of the Indian judicial system. A law postgraduate, she leverages her advanced legal education to bridge the gap between technical court rulings and public understanding, ensuring that readers stay informed about the rapidly evolving legal landscape. Expertise Advanced Legal Education: As a law postgraduate, Richa possesses the academic depth required to interpret intricate statutes and constitutional nuances. Her background allows her to provide more than just summaries; she offers context-driven analysis of how legal changes impact the average citizen. Specialized Beat: She operates at the intersection of law and public policy, focusing on: Judicial Updates: Providing timely reports on orders from the Supreme Court of India and various High Courts. Legal Simplification: Translating dense "legalese" into accessible, engaging narratives without sacrificing factual accuracy. Legislative Changes: Monitoring new bills, amendments, and regulatory shifts that shape Indian society. ... Read More