A Delhi Consumer Commission has directed a private health insurer to pay Rs 1.98 lakh to a Delhi man who paid for surgery in April 2024 after his claim was rejected over a 48-month waiting period for pre-existing diseases. The commission found that the insurer had failed to produce medical evidence establishing that his obstructive sleep apnoea existed before he bought the policy in 2021.The District Consumer Disputes Redressal Commission, South II, New Delhi president Monika Aggarwal Srivastava and members Dr Rajender Dhar and Ritu Garodia were hearing a complaint by a man, the complainant, who alleged wrongful rejection of his surgery claim seeking Rs 1.73 lakh in medical expenses, Rs 20,603 towards pre- and post-hospitalisation costs, 18 per cent annual interest, Rs 5 lakh compensation and litigation costs.“While settling the claims, the insurance company should not be too technical…Hence, we find the opposite party (the insurer) guilty of deficiency in service and unfair trade practice and direct to pay Rs 1,73,010 along with 7 per cent interest from the date of hospitalisation till payment, Rs 20,000 as compensation towards mental agony and harassment and Rs 5,000 as litigation cost,” the commission said on September 30.The complaint, instituted on August 14, 2024, arose after the insurer rejected both his cashless treatment request and subsequent reimbursement claim for surgery to treat severe obstructive sleep apnoea.Treatment continued before surgeryAccording to the complaint, he developed shortness of breath, nasal blockage and gasping during sleep in March 2022. He consulted a pulmonologist on March 28, 2022, and was diagnosed with obstructive sleep apnoea. A sleep study confirmed severe obstructive sleep apnoea, following which he was advised Auto CPAP therapy, medicines and nasal sprays.He remained under treatment at a private hospital in Faridabad from March 28, 2022, to April 12, 2023. After temporary relief for around five months, his symptoms returned. He subsequently consulted ENT specialists at another private hospital in New Delhi, where he received treatment from October 2023 to March 2024.When conservative treatment failed, doctors advised uvulopalatopharyngoplasty, functional endoscopic sinus surgery and bilateral submucosal diathermy under general anaesthesia. The surgery was scheduled for April 10, 2024. The hospital sought cashless authorisation from the insurer, which deputed an investigator to collect medical records. The request was not approved, and he proceeded with the surgery, paying Rs 1.73 lakh.Story continues below this adWhy insurer rejected claimThe insurer told the commission that his family health policy covered him, his spouse and daughter for a sum insured of Rs 1 crore. It said its investigation indicated that he had been using CPAP therapy since 2021 and had been suffering from depression since that year.The insurer said it sought treatment records through letters dated April 9, April 12 and April 15, 2024. Since the required documents were allegedly not furnished, it rejected the cashless request on April 15. The insurer maintained that the treatment concerned a pre-existing disease and cited the 48-month waiting period.He subsequently filed a reimbursement claim. The insurer sought additional documents but rejected the claim on May 4, 2024, invoking the policy’s 48-month waiting period for pre-existing diseases and their direct complications.The commission examined the policy, medical records, discharge summary and other documents. It noted that the policy had commenced on June 4, 2021, while the hospital records referred to nasal blockage for around two years at the time of admission.Story continues below this adHowever, the insurer had not produced any medical document, prescription or hospital record showing that he suffered from the condition before June 2021. The commission also found a discrepancy in the insurer‘s reliance on a statement allegedly made by the complainant’s father.Finding the insurer guilty of deficiency in service and unfair trade practice, the commission directed it to reimburse Rs 1,73,010 with 7 per cent interest from the date of hospitalisation until payment. It also awarded Rs 20,000 compensation for mental agony and harassment and Rs 5,000 towards litigation costs.TakeawayInsurers cannot reject a health claim merely by citing a pre-existing disease exclusion. They must support their decision with credible medical evidence. Policyholders should retain medical records, prescriptions, hospital bills and claim-rejection letters to challenge denials they believe are unjustified.For consumer-related grievances, individuals may contact the consumer helpline in their respective states (Delhi: 1800-11-4000) or call the National Consumer Helpline at 1915 for assistance.Story continues below this adDo not miss out on these stories:Customised sofa ‘10 inches wider’ than promised, Bengaluru man wins Rs 88,000Faulty equipment in powder coating plant ‘risks livelihood’, woman wins Rs 4.6 lakhNo stroke but knee surgery claim denied over its ‘missing records’, man wins Rs 2.8 lakh