The Jalandhar Consumer Disputes Redressal Commission has ordered Oriental Insurance Company Limited to pay over Rs 1.64 lakh after holding the insurer guilty of wrongly rejecting the mediclaim of a heart patient suffering from severe arterial blockage and a critical cardiac condition.
The commission directed the company to reimburse Rs 1,34,840 spent on the consumer’s treatment, along with Rs 20,000 as compensation for mental harassment and Rs 10,000 towards litigation expenses.
According to the complaint filed by Kulwant Singh, a resident of Shaheed Udham Singh Nagar in Jalandhar, he had purchased a Happy Family Floater Policy worth Rs 5 lakh from the insurer for the period between July 20, 2023, and July 19, 2024. He stated that he had been continuously insured with the company since 2016 without any break in coverage.
The complainant told the commission that in September 2023, he began experiencing chest pain and breathing difficulty while walking. Medical examinations and tests conducted at hospitals in Jalandhar reportedly revealed 90–95 per cent blockage in the arteries of his heart along with a critical cardiac condition after an angiography at a super-speciality hospital. Doctors subsequently advised early bypass surgery.
As per records placed before the commission, the complainant remained admitted to a hospital from September 25 to October 12, 2023, where he underwent treatment, including EECP therapy, aimed at improving blood flow to the heart. He was also kept in the ICU during the course of treatment.
However, when he later submitted a mediclaim of Rs 1,34,840 to cover the medical expenses, the insurer rejected it, stating that EECP was essentially an OPD procedure and that hospitalisation in the case was not justified under the policy terms.
Contesting the rejection, the complainant argued that his hospitalisation was medically necessary given the severity of his cardiac condition. The insurance company, on the other hand, maintained that the claim fell outside the policy coverage.
After examining the medical records, angiography reports and policy documents, the commission observed that while EECP is generally considered a non-invasive procedure, it cannot be treated as an absolute rule that such treatment never requires hospitalisation. It noted that a patient with severe coronary blockage may require continuous monitoring and supervised treatment in a hospital setting.
Calling the repudiation of the claim “arbitrary” and “not sustainable”, the commission, headed by President Harveen Bhardwaj along with members Jyotsna and Jaswant Singh Dhillon, in its April 24 order held the insurer guilty of deficiency in service. The commission observed that the company had rejected the claim on technical grounds despite the complainant suffering from a serious cardiac condition requiring hospitalisation and continuous medical supervision.
The commission further directed that the amount be paid within 45 days of receiving a copy of the order, failing which the entire payable amount would carry interest at 6 per cent per annum from the date of the order until its realisation.
