The Jalandhar Consumer Disputes Redressal Commission has mandated Oriental Insurance Company Limited to disburse over ₹1.64 lakh, finding the insurer liable for unjustly denying a mediclaim to a heart patient diagnosed with severe arterial blockage and a critical cardiac condition.
According to details received by The Chenab Times, the commission ruled that the company must reimburse ₹1,34,840, representing the expenses incurred for the consumer’s treatment. Additionally, the insurer has been ordered to pay ₹20,000 as compensation for the mental anguish suffered by the policyholder and ₹10,000 to cover litigation costs.
The complaint was lodged by Kulwant Singh, a resident of Shaheed Udham Singh Nagar in Jalandhar. Singh had acquired a Happy Family Floater Policy with a sum assured of ₹5 lakh, valid from July 20, 2023, to July 19, 2024. He asserted that he had maintained continuous insurance coverage with Oriental Insurance Company Limited since 2016 without any lapse.
Singh informed the commission that in September 2023, he began experiencing discomfort, including chest pain and difficulty in breathing, particularly during physical exertion. Subsequent medical evaluations and diagnostic tests conducted at Jalandhar-based hospitals indicated a significant blockage, ranging from 90 to 95 percent, in his heart’s arteries. An angiography performed at a super-speciality hospital confirmed a critical cardiac condition, leading doctors to recommend prompt bypass surgery.
Available records presented to the commission detailed Singh’s hospitalisation from September 25 to October 12, 2023. During this period, he underwent comprehensive treatment, which included EECP (Enhanced External Counterpulsation) therapy, a procedure designed to improve blood flow to the heart muscle. He was also admitted to the Intensive Care Unit (ICU) for close medical observation and management throughout his stay.
Following his treatment, Singh submitted a mediclaim request for ₹1,34,840 to cover his medical expenditures. However, the insurance company rejected the claim. The insurer’s justification for the repudiation was that EECP therapy is typically considered an outpatient department (OPD) procedure and that the patient’s hospitalisation was not warranted under the terms and conditions of the policy.
Challenging the insurance company’s decision, the complainant contended that his hospitalisation was medically essential, given the critical nature of his cardiac ailment. The insurance company, in its defence, maintained its stance that the claim fell outside the scope of the policy’s coverage, citing the nature of the treatment received.
After a thorough review of the medical records, the angiography reports, and the specific policy documents, the commission made its observations. While acknowledging that EECP is generally classified as a non-invasive procedure, the commission stated that it could not be universally applied to exclude the possibility of hospitalisation. The panel emphasised that individuals suffering from severe coronary artery blockages might necessitate continuous monitoring and structured therapeutic interventions within a hospital environment.
In its order dated April 24, the commission, presided over by President Harveen Bhardwaj, with members Jyotsna and Jaswant Singh Dhillon, deemed the repudiation of the claim as “arbitrary” and “not sustainable”. The commission found the insurance company guilty of providing deficient service. It noted that the company had rejected the claim on technical grounds, disregarding the complainant’s serious cardiac condition that required hospitalisation and ongoing medical supervision.
The commission further stipulated that the total payable amount must be settled within 45 days of the company receiving a copy of the order. Should the insurer fail to comply with this directive, the entire outstanding sum would accrue interest at a rate of 6 percent per annum from the date of the order until its full realisation.
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