Understanding Health Insurance Claim Rejections: A Landmark Case Explained

Understanding Health Insurance Claim Rejections: A Landmark Case Explained

The Delhi State Consumer Disputes Redressal Commission ruled against HDFC Insurance for rejecting a health insurance claim based on pre-existing conditions.

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In a significant ruling, the Delhi State Consumer Disputes Redressal Commission stated that health insurance claims cannot be denied solely because of pre-existing diseases. This decision came following a complaint filed by Anita Gupta against HDFC Life, where her claim was rejected due to her husband’s undisclosed pre-existing condition.

Anita’s husband had purchased a health insurance policy from HDFC Life but sadly passed away due to various health issues, including diabetes mellitus. When Anita filed a claim, it was rejected on the grounds of non-disclosure of his diabetes at the time of policy issuance. Seeking justice, Anita approached the state consumer commission, citing unfair trade practices.

The commission’s verdict highlights the importance of a direct link between the cause of death and the pre-existing disease concealed by the policyholder. It emphasized that if the concealed disease did not directly cause death, the insurer cannot reject the claim solely based on that ground.

The ruling is a relief for many individuals suffering from common lifestyle diseases like diabetes and hypertension. It ensures that insurance companies cannot deny claims based on such conditions if they did not directly lead to the insured’s demise.

As per the commission’s directive, HDFC Life was ordered to compensate Anita with the insured sum along with interest. Additionally, they were instructed to pay a substantial amount for the mental agony and harassment caused to Anita.

This case underscores the importance for health insurance customers to be transparent about their pre-existing conditions when applying for a policy. It also highlights the need for consumers to thoroughly understand their policy terms and conditions, especially regarding coverage for pre-existing diseases.

To avoid claim rejections, individuals should prioritize getting a complete health check-up before applying for insurance, disclose all pre-existing conditions accurately, and carefully read and understand the policy terms and conditions. Being informed about what is covered and what is not can prevent future disputes with insurance companies.