After undergoing surgery for abnormal uterine bleeding, a woman in Karnataka found herself facing another ordeal when her health insurer reportedly refused to reimburse her hospital bill, arguing that her condition existed before she bought the policy. She had to arrange the money for her treatment herself, despite having insurance cover. A Karnataka Consumer Commission directed the insurer to pay Rs 1.56 lakh.The Udupi District Consumer Disputes Redressal Commission president Sunil T Masaraddi and member Sujata B Koralli were hearing a complaint against a health insurance company and a private bank, alleging wrongful rejection of a health insurance claim despite coverage and seeking reimbursement of Rs 1,26,441 in hospital expenses, Rs 1 lakh in compensation for mental agony and inconvenience, and litigation costs.“The complainant, after undergoing hospitalisation and surgery, was compelled to arrange funds herself and thereafter pursue the insurer for reimbursement. In the circumstances, an award of reasonable compensation for mental agony and inconvenience is justified…Therefore, the rejection based solely upon the said history cannot be sustained,” the commission said on October 1, finding that the insurer had not sufficiently established the alleged pre-existing condition.The dispute arose after the woman was admitted to a hospital in Udupi on January 9 this year where she underwent a laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy on January 10. She was discharged on January 13. The insurer rejected her claim on February 10, alleging non-disclosure of a pre-existing medical condition.Insurer alleged non-disclosure of medical historyAccording to the complaint, the woman’s husband had obtained a group health insurance policy through the bank in August 2023. The policy provided a sum insured of Rs 5 lakh and was subsequently renewed.The insurer argued that medical records showed the woman had suffered from heavy menstrual bleeding for three to four years before the policy was first issued. It maintained that she had failed to disclose the condition while obtaining insurance and that the claim was inadmissible under the policy’s provisions concerning pre-existing diseases.The insurer also referred to medical records mentioning a previous lipoma excision while defending its decision. The woman challenged the rejection, maintaining that she had to arrange the hospital expenses herself despite having insurance coverage. She approached the commission seeking reimbursement, compensation and litigation costs.Insurer relied on medical recordsThe commission examined the hospital’s discharge summary, consultation sheets and other medical records. It noted that the discharge summary recorded heavy menstrual bleeding for approximately one-and-a-half years. Other records referred to a transvaginal sonography conducted on July 8, 2024, which revealed multiple fibroids.Story continues below this adThe commission found that the insurer had relied principally on an earlier consultation entry mentioning heavy menstrual bleeding with clots for three to four years. It held that this entry could not automatically be treated as conclusive proof of a pre-existing disease when the discharge summary and subsequent records indicated a different duration.The commission also noted that the insurer had not produced the insurance proposal form to establish what questions had been asked about the woman’s medical history or what answers she had provided. It found insufficient evidence to establish the alleged suppression or non-disclosure of material medical facts.The commission concluded that the insurer had failed to establish that the exclusion concerning pre-existing diseases justified rejecting the claim. It also examined the policy’s duration and the timing of the hospitalisation while considering the insurer‘s defence. The commission did not find the bank branch liable, holding that the evidence did not establish any specific deficiency in its service.TakeawayHealth insurance claims should not be rejected solely on the basis of an alleged pre-existing disease without sufficient supporting evidence. Consumers facing similar rejections should preserve their policy documents, proposal forms, medical records, claim correspondence and rejection letters, and can approach the appropriate consumer commission if they believe their claim has been unfairly denied.Story continues below this adFor consumer-related grievances, individuals may contact the consumer helpline in their respective states and Union territories (Karnataka: 1800-425-9339) or call the National Consumer Helpline at 1915 for assistance.Don’t miss out on these stories:Insurer rejects senior citizen’s car accident claim, he wins Rs 6.92 lakh consumer payoutInsurer rejects claim over expired licence after fatal crash, widow wins Rs 10 lakh55-year-old man loses Rs 4.8 lakh to ‘online fraud’, wins Rs 5 lakh from Canara Bank