Denied knee-replacement claim based on X-ray, man wins Rs 1.8 lakh from insurer

A Punjab consumer commission has directed a private insurance company to pay Rs 1.81 lakh to a 76-year-old man after it rejected his knee-replacement claim as a pre-existing, allegedly undisclosed condition. The commission held that the insurer produced no medical evidence proving prior diagnosis or deliberate non-disclosure by the insured.

A bench of president Aparana Kundi and members Mohinder Singh Brar and Priti Malhotra of the District Consumer Disputes Redressal Commission, Moga, also directed Rs 8,000 as compensation for harassing the complainant being a senior citizen, as well as litigation expenses to the complainant.

“The repudiation of the claim merely on the basis of the X-ray opinion regarding the disease being chronic/longstanding cannot be sustained. Accordingly, the repudiation of the claim by the Opposite Party is held to be unjustified,” the commission said on September 1.

The ruling held that just an inference drawn from the finding that the disease was chronic or longstanding cannot establish deliberate hiding of the condition in the absence of supporting medical records.

Moga resident denied claim

A 76-year-old resident of Moga had been insured under the insurance company’s Senior Citizen Red Carpet Health Insurance Policy. On November 24, 2024, he visited Sud Hospital, Jalandhar, for treatment of problems in both knees and was advised to undergo surgery. He was admitted on December 12, 2024, underwent replacement of both knees on December 13, and was discharged on December 17. He incurred medical expenses of Rs 2.63 lakh.

After he sought reimbursement, the insurer rejected his claim, stating that X-ray findings showed the knee condition was chronic and longstanding and that he had suffered from it before the policy began but had not disclosed it while obtaining the policy. The insurer relied on the policy condition concerning non-disclosure of crucial facts.

The complainant then approached the consumer commission seeking reimbursement of Rs 2.63 lakh, Rs 1 lakh compensation for mental harassment and deficient service, and Rs 50,000 towards litigation expenses.

Story continues below this ad

Complainant accepted policy terms: Insurer

The private insurance company argued that the complainant had concealed key facts relating to his health condition while taking the policy and hence was not entitled to the claim.

It submitted that the Senior Citizen Red Carpet policy covered only those pre-existing diseases that were specifically declared by the proposer. It also pointed to the policy’s 30 per cent co-payment clause and other terms accepted by the complainant.

The insurer relied on its medical assessment and X-ray findings, which indicated that the knee condition was chronic and existed before the policy’s inception. It maintained that the condition had not been disclosed in the proposal form and amounted to misrepresentation.

It further argued that the complainant had violated the policy terms and that the complaint involved complex questions that can’t be determined in consumer proceedings, and sought dismissal of the complaint.

Story continues below this ad

Disease falls under policy: Order

The commission noted that the insurance company rejected the claim on the ground that the complainant’s knee condition was longstanding and existed before the inception of the policy, but the insurer produced no previous medical record, prescription, diagnostic report, or treatment record to establish this.

“It is evident that treatment taken by the complainant for the disease in question falls under the policy in question, so the complainant is entitled to the claim in question,” it ruled.

The commission also noted that the policy had been continuously renewed, with the disputed claim arising in the third year of coverage. It found that the policy’s 24-month specified disease/procedure waiting period had already expired.

The order concluded that the complainant is, therefore, entitled to reimbursement of the admissible medical expenses in accordance with the terms and conditions of the policy.

Story continues below this ad

Takeaway

The ruling underscored that insurers cannot reject health claims solely on the basis of an X-ray indicating a chronic condition. They must produce credible medical evidence showing prior diagnosis, knowledge and deliberate non-disclosure of the alleged pre-existing disease.

Consumers facing similar grievances may contact the consumer helpline in their respective states (Punjab helpline: 1800-425-1082) or dial the National Consumer Helpline at 1915 for assistance.

Don’t miss out on these stories:

Man claims bus conductor ‘chewed’ his ticket, ‘threw’ bag out, awarded Rs 60,000 payout

Senior citizen’s US-bound gifts not delivered, courier firms ordered to pay Rs 41,000

Story continues below this ad

Woman, baby kept waiting 10 hours on plane, airline ordered to pay Rs 1.5 lakh