Star Health insurance told to pay ₹2.9 lakh to heart patient: DCRDC Ranga Reddy
HYDERABAD: The District Consumer Disputes Redressal Commission, Ranga Reddy, has directed Star Health and Allied Insurance Co. Ltd. to reimburse ₹2,99,839 to a policyholder after holding that the insurer wrongly repudiated his mediclaim on grounds of pre-existing disease.
The order was pronounced on February 20, 2026, in a complaint filed on November 21, 2023, by Devulapally Suresh Kumar, 48, a businessman from Jawahar Nagar, Moula-Ali.
Treatment during policy period undisputed
According to the complaint, Suresh Kumar was admitted to Yashoda Hospital, Secunderabad, on March 28, 2023, with chest pain. Doctors diagnosed him with Coronary Artery Disease (CAD) and Acute Coronary Syndrome – Anterior Wall Myocardial Infarction. He underwent a coronary angiogram followed by primary Percutaneous Transluminal Coronary Angioplasty (PTCA) with stent placement to the Left Anterior Descending (LAD) artery through the right radial artery.
He sought cashless treatment under his Family Health Optima policy , valid from December 5, 2022, to December 4, 2023, with a floater sum insured of ₹5,00,000. The insurer had collected a premium of ₹21,882.
However, the company denied pre-authorisation on March 31, 2023, stating that hospital records suggested a “longstanding ailment” and that the duration of the disease could not be ascertained. The claim was later repudiated on April 17, 2023, on the ground that CAD was a pre-existing disease under Exclusion 01 of the policy, which bars coverage for 48 months from inception.
Insurer failed to prove suppression, says panel
The insurer contended that the complainant had not disclosed material facts in the proposal form, including hypertension and Type 2 diabetes. It relied on Supreme Court judgments in Sony Cherian vs Oriental Insurance Co. Ltd. (1999) 6 SCC 451 and Satwant Kaur Sandhu vs New India Assurance Co. Ltd. (2009) 8 SCC 316 to argue that insurance contracts are based on utmost good faith.
The commission observed that the policy was in force when the complainant was hospitalised. It noted that apart from a prescription dated March 21, 2023, the insurer had not produced cogent evidence to establish that the complainant suffered from CAD prior to policy commencement.
The panel held that hypertension and diabetes are common conditions and, in the absence of proof linking them to the cardiac event, the insurer could not presume suppression of material facts.
Relying on the Supreme Court ruling in Manmohan Nanda vs United India Insurance Co. Ltd., the commission said that once a policy is issued after assessing the insured’s medical condition, the insurer cannot repudiate a claim without substantive evidence of concealment.
It termed the repudiation an unfair trade practice and deficiency in service.
Relief granted with interest and compensation
Allowing the complaint in part, the commission directed the insurer to:
Pay ₹2,99,839 towards hospital expenses with 9% interest per annum from April 10, 2023, till realisation.
Pay ₹25,000 as compensation for mental agony.
Pay ₹10,000 towards litigation costs.
The insurer has been given 45 days to comply, failing which the interest rate will stand enhanced to 12% per annum from April 10, 2023, till realisation.
