A consumer commission in Rohtak has ruled against an insurance company’s defence that a policyholder’s heart condition was a pre-existing disease. The commission ordered the insurer to reimburse more than Rs 4.11 lakh to Ashok Kumar, a resident of Sangahera village, who underwent bypass heart surgery.
Policyholder’s Claim Rejected After Bypass Surgery
Ashok Kumar had purchased a health insurance policy with a sum insured of Rs 5 lakh after paying a premium of Rs 27,895. The policy was valid from April 11, 2024, to April 10, 2025. In August 2024, he developed chest pain and was initially examined before being referred to a cardiologist. He was later admitted to a private hospital in Delhi, where he underwent coronary artery bypass grafting (CABG).
According to the original story, the insurance company repudiated his claim, arguing that the heart condition was a pre-existing disease. However, the District Consumer Disputes Redressal Commission, Rohtak, headed by President Nagender Singh Kadian, held that the claim was wrongly repudiated.
Commission Orders Reimbursement with Interest
The commission directed the insurance company to reimburse more than Rs 4.11 lakh to the policyholder. In addition, the insurer was ordered to pay interest and compensation for the wrongful denial of the genuine mediclaim.
The ruling underscores that insurers cannot arbitrarily reject claims by labelling conditions as pre-existing without proper evidence or policy terms. The commission’s decision provides relief to policyholders who face similar rejections.
Our Take: A Win for Policyholder Rights
This case is a clear reminder that insurance companies cannot use vague defences to avoid paying legitimate claims. The Rohtak commission’s decision sends a strong message: policyholders who pay premiums in good faith deserve fair treatment. In our view, such rulings are essential to hold insurers accountable and ensure that health insurance serves its purpose — providing financial support during medical emergencies. Policyholders should not hesitate to challenge wrongful rejections through consumer forums.