Chandigarh consumer panel directs insurer to pay ₹72k medical claim

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.

The panel also enhanced compensation for mental agony and harassment from ₹10,000 to ₹25,000 alongside litigation costs from ₹10,000 to ₹15,000. Delivered on August 20 by a bench of president justice Raj Shekhar Attri and member Preetinder Singh, the order partly allowed an appeal filed by Sudipta Bedbak against the District Consumer Commission-I’s verdict dated November 3, 2025.

The dispute arose after Bedbak’s mother, who was covered under the health policy, was admitted to Fortis Hospital, Mohali, on April 30, 2024. 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.

Challenging the decision, the complainant produced medical records demonstrating that insulin therapy only commenced in 2023. Although the insurer cited an initial Fortis record describing the patient as a 20-year Type-2 diabetic using insulin and oral medications, the commission highlighted that the hospital subsequently corrected this entry. 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 panel also observed that the insurer had later offered policy continuation under its “Diabetic Care Freedom Product” with a permanent diabetes exclusion. Although the complainant accepted, the policy status was later marked as “expired” without a satisfactory explanation from the company regarding its inconsistent approach. Reviewing the finances, the commission ruled that the policy’s “No Claim Bonus Protect” clause elevated the sum insured to ₹20 lakh. 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.

This additional sum will carry a 9% simple interest from May 14, 2024, until realisation. The directive to restore and continue the policy without a gap also stands, subject to premium payments. The insurer must comply within 45 days of receiving the certified order, failing which the principal amounts will attract a 12% simple interest.