The burden of proving that a medical condition was a pre-existing disease to justify the repudiation of an insurance claim lies entirely with the insurer.

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1 A/450/2020

Date of filing :11.09.2020

Date of order :25.05.2026

MAHARASHTRA STATE CONSUMER DISPUTES REDRESSAL

COMMISSION,MUMBAI, BENCH AT AURANGABAD.

FIRST APPEAL NO. : 450 OF 2020

IN COMPLAINT CASE NO.: 1155 OF 2016

DISTRICT CONSUMER FORUM : NANDED

The United India Insurance Co.Ltd. ...APPELLANT

Through its Manager, (Adv.S.V.Kulkarni)

Through its Divisional Office

Osmanpura, Aurangabad 431 001.

VERSUS

1. Harvindersingh S/o Bahadursingh Ratan...Respondent no.1

R/o Sanghavi(BK), Tq. Dist.Nanded (Adv.Ratan)

2. Manager/Authorised Representative, ...Respondent no.2

Andhra Bank, Ex-parte)

Goodhealth TPA Service Pvt.Ltd.

Andhra Bank Branch Nanded,

Near Taj Patil Hotel, VIP Road.

3. Manager/Authorised Representative, ...Respondent no.3,

Goodhealth TPA Service Pvt.Ltd. (Ex-parte)

Plot No.49, Nagarjun Hills, Poonjagutta,

Hyderabad 500 009.

Hyderabad , Telangana.

CORAM : Milind.S.Sonawane, Hon’ble Presiding Member.

Nagesh.C.Kumbre, Hon’ble Member

2 A/450/2020

J U D G M E N T

(Delivered on 25/05/2026)

Per Milind S.Sonawane, Hon’ble Presiding Member.

In this appeal this Commission has been called upon to

decide as to whether the repudiation of the health insurance

claim of respondent by the appellant on the ground of pre-

existing disease was legal, valid and justified or not.

2. Respondent no.1 had took mediclaim policy for himself and

his family on 28/07/2015. Thereafter in 2016 he renewed the

same. The sum insured was Rs.5 lakhs. On 26/08/2016 he was

not feeling well and therefore initially went to Dr.Umarekar. He

was treated by him from 26/08/2016 to 27/08/2016. However,

he was advised by Dr.Umarekar to go to Aurangabad and

accordingly he gets admitted on 27/08/2016 in Cigma Hospital,

Aurangabad. On the angiography four blockages were found.

Those were removed and four stents were inserted. He was

admitted in that hospital till 30/08/2016. He incurred expenses

of Rs.46,268/- on the treatment. Even though he requested the

appellant to provide cashless facility as per the terms of the

policy but it was not given. Thereafter, in the month of

September,2016 he undergone angioplasty at Kamalnayan Bajaj

Hospital and Marathwada Medical and Research Centre. He

incurred expenses of sum of Rs.3,51,381/- for it. At that time

also no cashless facility was given by the appellant. After the

discharge he filed insurance claim with the appellant with all

requisite documents. However, his claim has not been considered

3 A/450/2020

by the appellant despite of his submission of all the necessary

documents required and demanded from time to time by the

appellant. Thus, he filed Consumer Complaint No.1155/2016

before the learned District Consumer Disputes Redressal

Commission, Nanded ( the ‘District Commission’ for short).

3. The appellant took stand before the District Commission

that, respondent no.1 has without furnishing the complete

information about the disease and original documents sought for

the cashless facility. Similarly when it revealed to them that, the

disease for which he was treated was pre-existing. Thus, the

cashless facility is denied to him. The he never provided them the

complete set of papers relating to the treatment of the disease.

As per the terms and conditions of the policy the insured was

under the obligation to inform about his admission within 24

hours but he intimated them after 46 hours and that too with

incomplete set of papers. On these grounds his insurance claim

is rightly been repudiated. There is no deficiency in service on

their part.

4. The District Commission on evaluating the evidence reached

the conclusion that, so far as the cashless facility is concerned it

is seen from the Pre-authorisation Ticket No.613346 that no such

documents we