Case Title: Surilla Mathur vs M/s Oriental Insurance Co. Ltd
Case Number: First Appeal 26/2015
Forum: Delhi State Consumer Disputes Redressal Commission
Coram: Hon’ble Justice Sangita Dhingra Sehgal (President), Ms. Pinki (Member – Judicial)
📜 Background
Surilla Mathur, a senior citizen, purchased an Overseas Mediclaim Insurance Policy from Oriental Insurance Co. Ltd. for her trip to Singapore. During her visit, she suffered from cardiac complications, leading to hospitalization and urgent medical treatment abroad.
Her son promptly informed the insurer and requested cashless treatment, which was declined. Following her return, all treatment documents were submitted for reimbursement, but the claim was denied on the grounds of a pre-existing illness (heart disease), allegedly excluded under Clause 11 of the policy.
⚖️ District Forum Decision
The District Consumer Forum sided with the insurer, holding that the treatment arose from a pre-existing disease and that even if the insured was unaware of the condition, the claim could still be repudiated.
🧾 Appeal & Findings by Delhi State Commission
Upon appeal, the Delhi State Commission reversed the District Forum’s order, delivering a well-reasoned judgment in favor of the complainant. Key points from the Commission’s findings are outlined below:
1. ❌ No Medical Examination = No Presumption of Pre-Existing Disease
The Commission emphasized that no pre-policy medical examination was conducted by Oriental Insurance. In the absence of such a test, the onus was on the insurer to prove the existence of any pre-existing condition.
“The insurer cannot later claim exclusion for conditions it failed to detect due to its own omission.”
2. 💉 Lifestyle Diseases Not Sufficient to Deny Claims
The insurer had cited diabetes and hypertension as indirect contributors to the cardiac condition. The Commission rejected this argument, stating:
“Hypertension and diabetes are common lifestyle diseases and cannot be presumed to be pre-existing without clinical corroboration.”
3. 📄 Interpretation of Policy Clauses
Clause 11 of the policy, which excludes pre-existing conditions, was discussed. The Commission ruled that such clauses must be interpreted strictly and cannot be applied arbitrarily.
“A clause excluding liability must be interpreted narrowly and cannot be invoked without concrete proof.”
4. 📚 Reliance on Precedents
The Commission referred to:
- Pradeep Kumar Garg vs National Insurance Co. Ltd: Emphasizing the burden on insurers to prove pre-existing conditions.
- Sunil Kumar Sharma vs TATA AIG Life Insurance Co.: Holding that a claim cannot be denied merely because the disease is common or may have developed over time.
✅ Final Order
The Delhi State Commission allowed the appeal and directed Oriental Insurance Co. Ltd. to:
- Reimburse the claim amount to the complainant.
- Pay interest on the delayed payment.
- Compensate for mental harassment and litigation costs.
The insurer’s refusal to honor the claim was held to be deficiency in service and unfair trade practice.
🧠 What This Means for Policyholders
This judgment serves as a critical precedent protecting policyholders from arbitrary claim denials. Here’s why it matters:
- Insurers must perform due diligence (like health tests) before issuing policies.
- They cannot deny claims based on medical assumptions or retrospective logic.
- Policyholders have the right to challenge unfair repudiation.
📩 Facing a Similar Issue?
If your health insurance claim has been denied on vague grounds of a “pre-existing condition,” and no medical test was done before your policy started — you may have a strong case.
Contact iClaimSupport for expert help in understanding and pursuing your rightful insurance claims.
📧 Email: contact@iclaimsupport.in
📞 Phone: 9871820066
🌐 Website: https://iclaimsupport.in
🔍 Important Note
This article is for general information. Every case depends on its own facts and evidence. If you’re facing a claim dispute, the best course is to seek advice tailored to your individual situation.
