The national consumer disputes redressal commission (NCDRC) has directed United India Insurance Company Ltd to settle a medical insurance claim of Rs8.95 lakh with 9% annual interest in favour of Delhi resident Satish Garg, who was denied reimbursement of expenses incurred during a cardiac procedure in 2011. The ruling, delivered last month by a bench of Dr Inder Jit Singh and justice Dr Sudhir Kumar Jain, dismissed the insurer’s revision petition and upheld the earlier order of the Delhi state consumer commission.
The commission agreed with the state commission’s finding that Mr Garg had taken a super top-up medicare policy as an additional cover, not as a replacement for his family medicare policy. It upheld that the family medicare policy had been in force since 10 August 2007, meaning the 48-month exclusion period for pre-existing conditions had lapsed by the time of his 2011 hospitalisation. Since Mr Garg’s last treatment was in 2006, the exclusion clause did not apply and he was entitled to reimbursement under both policies.
"There is no force in argument advanced by the counsel for the insurance company that Mr Garg in connivance with one of the employee of United India Insurance has changed the validity of family medicare policy to 10 August 2007 as no such plea has been taken by the insurer either before the district forum or the state commission. We are also of the opinion that there was deficiency in service on the part of United India Insurance in repudiating the claim of Mr Garg," the bench says.
Mr Garg, a former manager with Yamaha Motor Pvt Ltd, retired in 2003 under a voluntary retirement scheme. His employer had provided a group medical policy until October 2008, after which he purchased a family medicare policy from United India Insurance. In 2010, he supplemented it with a super top-up medicare policy to cover higher hospitalisation costs.
On 11 August 2011, Mr Garg suffered a heart attack and was admitted to Medanta Medicity Hospital in Gurgaon, where he underwent device implantation surgery and was discharged on 14 August 2011 after spending Rs8,95,010 on treatment. When he filed for reimbursement, the insurer repudiated his claim, citing pre-existing disease under clause 4.1 of the policy.
In 2013, the district consumer forum dismissed Mr Garg’s complaint, agreeing with the insurer’s stand that his previous cardiac history made the expenses ineligible under the policy until 48 months of continuous coverage.
Mr Garg appealed, and in 2016, the Delhi state consumer commission overturned the decision. It held that Mr Garg's family medicare policy had been continuously in force since 10 August 2007 and that he had last undergone treatment in 2006, meaning the 48-month exclusion period had already expired by the time of his hospitalisation in 2011. The state commission ruled that the insurer’s repudiation of the claim amounted to a deficiency in service and ordered payment of the claim with interest.
United India challenged the state commission’s ruling before NCDRC, contending that the exclusion clause applied and that there had been misrepresentation of facts.
NCDRC rejected these arguments, noting that Mr Garg had supplemented rather than replaced his family medicare policy with a super top-up cover and that the inception date of his policy had been endorsed as 10 August 2007. It found no evidence that he had taken treatment within 48 months prior to his hospitalisation in 2011. The commission concluded that the insurer was at fault in repudiating the claim.
NCDRC directed United India Insurance to pay Rs8,95,010 to Mr Garg along with 9% annual interest from the date of repudiation until realisation and Rs25,000 towards litigation costs, with compliance required within two months.
The decision, coming after a legal battle that lasted more than a decade, underscores the accountability of insurers in interpreting exclusion clauses fairly and strengthens consumer protection in mediclaim disputes.
(Revision Petition No332 of 2017 Date: 14 August 2025)
