August 4, 2025 |
In a significant ruling for health insurance policyholders, the Nashik District Consumer Disputes Redressal Commission has ordered a private insurer to pay ₹2.1 lakh to a claimant after finding that hypertension alone is not a valid ground to deny a hospitalisation claim.
The case sets a precedent on how insurers treat common pre-existing conditions like high blood pressure, and reaffirms the requirement for clear disclosure — but also fair interpretation — under insurance contracts.
The Case: Claim Denied After Hospitalization
The complainant, a 62-year-old retired teacher, was hospitalised in 2022 due to chest discomfort and related cardiac symptoms. Although he had a valid health insurance policy with the insurer for over four years, his cashless claim of ₹2.1 lakh was denied.
The insurer cited that the claimant had undisclosed hypertension, and argued that it constituted a material non-disclosure which invalidated the coverage.
Tribunal’s Take: “Hypertension Is Not a Conclusive Cause”
After examining the medical records and consulting the hospital’s discharge summary, the consumer court ruled that hypertension was not the root cause of the emergency hospitalisation — and could not be used as a blanket reason to reject the claim.
“Merely having high blood pressure cannot automatically mean the policyholder failed failed to disclose critical health information,” the tribunal observed. “There was no evidence that hypertension directly caused the ailment requiring hospitalisation.”
Final Verdict & Compensation
The district forum directed the insurer to:
- Pay ₹2.1 lakh as the original claim amount
- Add ₹10,000 towards mental agony and litigation expenses
- Settle the amount within 30 days, or attract penal interest
Why This Ruling Matters
This judgment sends a strong signal to insurers on how they interpret pre-existing conditions and claim rejections. With lifestyle conditions like hypertension affecting millions of Indians, blanket denials may now face more legal scrutiny — especially when:
- The condition is medically controlled
- It wasn’t the direct cause of hospitalisation
- The insured has renewed policies over several years
“This judgment reinforces the importance of fair claim assessment and serves as a reminder to insurers that medical nuances must be weighed carefully — because for policyholders, every denied claim carries real-life consequences.“
As more policyholders challenge unfair claim rejections, regulators are pushing insurers to take accountability seriously. Read how IRDAI’s proposal for internal ombudsmen aims to streamline complaint resolution within the insurance system.
