Insurer denies depression treatment claim citing ‘self-injury’, woman wins Rs 1.47 lakh
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“Insurance companies cannot exonerate their liability on mere technical grounds. Since the medical expenses incurred are fully supported by valid hospital bills, and the act of repudiating the claim of the complainant by the OP insurance company amounts to a clear deficiency in service…we found that the insurance company deficient in its service in repudiating the claim of the complainant on technical ground,” commission said on September 29.
The complainant informed the commission that she held a ‘Family Health Optima’ policy and relied on its provisions relating to the moratorium period and grace period. She argued that the policy’s long renewal history and the applicable grace-period provisions supported her claim.
The commission allowed the complaint and directed the opposite parties to pay the complainant Rs 1.45 lakh jointly and severally. The amount must be paid within 30 days of the order. If the opposite parties fail to comply, they must pay interest at 6 per cent per annum from November 18, 2025, the date the complaint was filed, until realisation.
The commission also awarded Rs 2,000 towards the cost of the proceedings. It directed the opposite parties to submit a compliance report within 45 days of receiving the order.
If your health insurance claim is rejected by citing a policy exclusion, check whether the insurer’s reason is supported by your medical records and the policy terms. If you believe the rejection is unjustified, you can challenge it before a consumer commission.
For 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.
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