30-04-2025
Insurer can't reject claim over diabetes non-disclosure, rules Bengaluru consumer forum
Bengaluru: Diabetes, though a common lifestyle condition, can't be treated as a non-disclosed pre-existing illness when it comes to health insurance, the IV additional Bengaluru Urban district consumer commission ruled recently. It termed an insurer's denial of an elderly couple's claim a deficiency in service and ordered it to pay Rs 76,000 to clear the claim.
The case involved Ashok, 65, and his wife Suma, 62, from Jayanagar V Block, who had a floater group health insurance policy worth Rs 10 lakh from
Bajaj Allianz Life Insurance
Co Limited, Rajajinagar. Ashok had regularly renewed the policy since Jan 2022, and had paid a premium of Rs 52,958 for the term from Jan 18, 2024 to Jan 17, 2025.
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During the policy period, Suma underwent treatment for a right eye branch retinal vein occlusion, which involved a full-thickness macular hole and vitreous haemorrhage. She received an injection costing Rs 21,000 on March 21, 2024, followed by surgery on March 28, costing Rs 55,000, bringing the total to Rs 76,000. The couple submitted a claim to the insurance company, which was rejected on June 27. It cited that Suma had been a 'known case of diabetes mellitus' for 14 years and alleged that this was not disclosed in the proposal form. The insurer claimed the eye condition was a diabetes-related complication.
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The couple, however, argued that the insurer had failed to provide any valid reason for denying the claim and filed a complaint with the commission on Aug 14, 2024.
Though the insurer responded through legal counsel and submitted a written version, it failed to file its chief examination affidavit, despite multiple chances. The forum thus considered the evidence as not submitted.
After reviewing the documents, the commission noted Suma had undergone surgery at Brillanz Centre for Eye Surgery, Vijayanagar, where the doctor stated her condition was likely age-related.
The insurance company denied all allegations and any deficiency in service. While it acknowledged issuing the policy, receiving premiums, and confirmed its validity, the insurer argued that the complainant had failed to disclose a pre-existing condition at the time of purchasing the policy.
Citing a precedent set by National Consumer Disputes Redressal Commission in a similar case, the consumer forum said in its judgement, "As the complainant has diabetes mellitus, non-disclosure of this fact doesn't amount to suppression of facts; it is a common disease, and it doesn't amount to suppression of material illness."
The commission further stated the firm was indeed guilty of deficiency in service. "As per the insurance contract, once the company has agreed to indemnify the insured for unforeseen medical events, it is bound to compensate for valid claims covered under the policy," it said.
It directed the insurer to clear the couple's claim of Rs 76,000, with 6% interest from June 27, 2024 until the date of payment. Additionally, the firm has to pay Rs 10,000 for deficiency in service and Rs 10,000 to cover litigation costs.
