Ruling that Care Health Insurance Ltd failed to establish claims of concealed medical history, the State Consumer Disputes Redressal Commission has directed the firm to pay an additional ₹ 72,532 towards an insured policyholder’s medical expenses.
Following treatment, the insurer denied cashless authorisation and subsequently repudiated the claim on the grounds that her diabetes and insulin usage had been concealed when taking the policy. The bench noted that the insurer failed to provide independent medical evidence proving the corrected record was unreliable or that insulin use predated the policy. Furthermore, it could not identify any false declarations in the proposal form, rendering the repudiation unsustainable.
The dispute arose after Bedbak’s mother, who was covered under the health policy, was admitted to Fortis Hospital, Mohali, on April 30, 2024. Challenging the decision, the complainant produced medical records demonstrating that insulin therapy only commenced in 2023. the commission highlighted that the hospital subsequently corrected this entry Although the insurer cited an initial Fortis record describing the patient as a 20-year Type-2 diabetic using insulin and oral medications.
Against total medical bills of ₹ 10.72 lakh, after accounting for ₹ 45,997 previously paid and ₹ 9.54 lakh awarded by the district commission, a balance of ₹ 72,532 remained due.
The panel also observed that the insurer had later offered policy continuation under its “Diabetic Care Freedom Product” with a permanent diabetes exclusion. the policy status was later marked as “expired” without a satisfactory explanation from the company regarding its inconsistent approach Although the complainant accepted. Reviewing the finances, the commission ruled that the policy’s “No Claim Bonus Protect” clause elevated the sum insured to ₹ 20 lakh.
