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Insurance Company Ordered to Pay After Wrongfully Denying Mediclaim for “Pre-Existing” Heart Condition
January 7, 2026 : In a significant ruling for policyholders, the District Consumer Disputes Redressal Commission in Bilaspur, Chhattisgarh, has ordered the Oriental Insurance Company to settle a medical claim it had previously rejected on the grounds of a pre-existing disease. The commission, led by President Anand Kumar Singhal and members Purnima Singh and Alok Kumar Pandey, found that the insurer failed to prove the claimant had prior knowledge of his heart condition before the policy was issued.
The case originated when Ramesh Sihote, a resident of Kasturba Nagar, filed a complaint after his claim for an open-heart surgery was dismissed. Sihote had been a long-term policyholder with another firm before being persuaded by Punjab National Bank—acting as a corporate agent—to port his coverage to the PNB Oriental Royal Mediclaim policy in December 2017. Although the insurer argued the policy was a “new” contract rather than a ported one due to a slight lapse in the renewal timeline, the focus of the legal battle shifted to the legitimacy of the claim itself.
In September 2018, during a routine general checkup at Alexis Hospital in Nagpur, Sihote was informed for the first time that he had significant arterial blockages. Following medical advice, he underwent surgery at Platina Heart Hospital, incurring expenses totaling ₹2,54,713. When he submitted these bills for reimbursement, Oriental Insurance rejected the claim, asserting that the heart disease was a “pre-existing condition” that predated the policy.
However, the Commission observed that the insurance company provided no medical evidence or investigative reports to prove that the complainant was aware of or being treated for the condition prior to the policy’s commencement. Furthermore, the Commission noted that in the original proposal form, the sections regarding health status were left blank, yet the insurer issued the policy anyway. The court ruled that a condition cannot be labeled “pre-existing” unless it was previously diagnosed by a physician or the patient was actively receiving treatment for it.
Concluding that the denial of the claim constituted a deficiency in service, the Commission ordered Oriental Insurance Company to pay the full surgical cost of ₹2,54,713. Additionally, the insurer must pay 9% annual interest on this amount, calculated from the date the complaint was filed in April 2019. To compensate for the mental agony and legal costs incurred by Sihote, the company was also directed to pay an additional ₹15,000. While the bank was exonerated of any wrongdoing, the ruling serves as a stern reminder to insurers regarding the burden of proof required to deny health claims.
Case Reference : Ramesh Sihote Vs. Oriental Insurance Company Ltd. & Anr
