A Delhi family secured a significant win against M/S Oriental Insurance Co. Ltd. on March 3, 2025. The Delhi State Consumer Disputes Redressal Commission upheld an earlier ruling, directing the insurer to settle unpaid medical claims. This case underscores the need for trust and clarity in insurance policies. It offered relief to a family grappling with loss and financial challenges. ⚖️✨
In 2012, an 81-year-old Delhi resident—referred to as Mr. Sharma—purchased a mediclaim policy from Oriental Insurance. He renewed it in 2013, covering him and his wife for up to ₹5 lakh each. In October 2013, Mr. Sharma fell seriously ill. He was first treated for septicemia at Sri Balaji Action Medical Institute, then for stomach and prostate issues at Jaipur Golden Hospital.
The medical costs reached ₹2.77 lakh, paid from his own pocket. He sought reimbursement from Oriental Insurance, but they provided only ₹92,814, citing pre-existing conditions for the rest. Dissatisfied, Mr. Sharma filed a case with the District Consumer Court in 2016. That court ruled in his favor in 2017.
Oriental Insurance appealed to the Delhi State Consumer Disputes Redressal Commission. By 2025, Mr. Sharma had passed away, and his wife and son continued the fight for his claim. 🏥📜
Mr. Sharma’s family argued he met all policy terms. He paid premiums consistently, expecting support during illness. They submitted records of his 2013 hospital stays—₹1.70 lakh for the first and ₹1.07 lakh for the second.
They questioned the pre-existing condition label, noting no prior hospital visits for these issues before the policy. They felt misled by Oriental Insurance and sought the full amount owed, stressing fairness after years of hardship. 💔🙏
Oriental Insurance defended their stance, citing policy rules. They stated that certain illnesses weren’t covered in the first two years unless newly diagnosed. They linked Mr. Sharma’s high blood pressure and past stroke to his 2013 claims.
They referenced clauses 4.1 and 4.2, asserting these terms were explicit. After the 2017 District Court loss, they appealed, claiming the ₹92,814 paid was sufficient. They emphasized compliance with policy conditions. 📋🚫
The Delhi State Consumer Disputes Redressal Commission, led by Justice Sangita Dhingra Sehgal, examined the case carefully. Their findings included:
- A pre-existing condition requires proof of recent hospital treatment before the policy. Oriental Insurance lacked evidence of such for Mr. Sharma, weakening their case. 🩺
- The insurer cited exclusion clauses, but no proof showed Mr. Sharma received them during the 2013 renewal. “Terms must be communicated to be valid,” the court ruled. 📜⚖️
- “Insurers must verify health before issuing policies,” the court affirmed. Oriental Insurance skipped this step and couldn’t shift blame. 🩺
- Insurance demands mutual honesty. Without sharing terms, Oriental Insurance couldn’t deny the claim. 🤝
On March 3, 2025, the Commission rejected Oriental Insurance’s appeal. They upheld the 2017 District Court decision. The insurer was ordered to pay Mr. Sharma’s family—his wife and son—₹1.84 lakh.
They must also pay 6% interest from 2017 until settled, plus ₹10,000 for the family’s difficulties. This ruling highlights the need for transparency in insurance. For the family, it closes a long struggle with a fair outcome. 💰✨
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