A district consumer commission in Haryana has ordered Care Health Insurance to pay the remaining $90,000 of a medical claim to a 73-year-old woman who underwent emergency heart treatment in the United States, ruling that the insurer could not slash her claim to 10% by arbitrarily citing pre-existing diabetes.
Key Details of the Case
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The Incident and Treatment: The couple had purchased a travel insurance policy with a $100,000 sum insured for a trip to the US. While there in March 2022, the woman suffered a heart attack and acute heart failure, requiring emergency angioplasty with total hospital bills amounting to $145,838.
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Full Disclosure Ignored: The policyholder had explicitly disclosed her diabetes at the time of purchase, and the insurer accepted the risk and issued the policy without any specific endorsements excluding cardiac coverage. However, the insurer later restricted its payout to just 10% (around $9,900), invoking clauses related to pre-existing conditions.
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The Commission’s Ruling: The consumer panel rejected the insurer’s defense, noting that Care Health Insurance failed to provide medical evidence linking her diabetes to the sudden heart attack. The commission emphasized that an insurer cannot accept a premium with full knowledge of a pre-existing condition and later use it as a technical ground to truncate liability at the claim stage.
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Penalties and Compensation: The commission ruled that the payout reduction constituted a deficiency in service and an unfair trade practice. It directed the company to disburse the remaining $90,000 (converted to Indian rupees) with 9% annual interest from March 2022, alongside an additional ₹1 lakh for mental agony and ₹22,000 in legal expenses.
