National Insurance rejects mediclaim over 'hidden hypertension': Court says insurers can't deny genuine claims without evidence; orders over Rs 2 lakh payout

National Insurance Company has been directed to pay Rs 2,25,000 to a Thrissur resident whose mediclaim was rejected on the grounds that his heart condition stemmed from a pre-existing case of hypertension, after a Kerala consumer commission ruled that the insurer never actually proved it.

The order was passed on 29 June 2026 by the Consumer Disputes Redressal Commission, Thrissur, nearly 13 years after the man first filed his complaint in March 2013.

Mediclaim Rejection and the Angioplasty Bill


The complainant held a Parivar Mediclaim Policy with National Insurance Company covering the period from 31 March 2012 to 30 March 2013. In July 2012, he developed chest pain and was admitted to Aswini Hospital in Thrissur, where he underwent angioplasty between 25 and 30 July 2012.

The total hospitalisation and treatment bill came to Rs 2,02,977. He submitted his claim along with all required documents. National Insurance rejected it on 11 February 2013, citing a single reason: the condition was a pre-existing disease and therefore excluded under the policy.

He sent a lawyer's notice in February 2013 seeking settlement. The insurer did not respond. He then approached the consumer commission.

National Insurance Pre-Existing Disease Argument

National Insurance argued that the man had been suffering from hypertension, diabetes, and dyslipidemia before he took out the policy. It pointed to records from Daya Hospital suggesting he had been undergoing treatment for hypertension and diabetes since 15 September 2010.

The insurer's position was that the coronary artery disease that led to the angioplasty was a direct complication of this pre-existing hypertension. It also alleged that he had suppressed the fact of his hypertension while filling the proposal form, having disclosed only his diabetes, for which an additional premium was paid.

On this basis, National Insurance maintained that the repudiation was entirely justified and sought dismissal of the complaint.

What the Thrissur Consumer Commission Found

The commission examined the evidence carefully and found National Insurance's case to be built almost entirely on assertion rather than proof.

On the question of pre-existing hypertension, the commission found that no reliable medical evidence had been produced to conclusively establish that the man was under treatment for hypertension before the policy began. Crucially, no expert medical testimony was placed on record to establish a direct link between any alleged hypertension and the coronary artery disease that necessitated the angioplasty.

The commission noted that the complainant was cross-examined at length but nothing emerged to suggest he had suppressed any material fact. When the insurer's own witness was cross-examined, no satisfactory explanation was offered for the absence of conclusive evidence.

The commission stated plainly: mere assertions in a written version or affidavit are not sufficient to establish a pre-existing disease. The insurer had ample opportunity to produce convincing evidence and chose not to.

Insurers Cannot Use Assumptions to Reject Claims

The commission's ruling rested on a principle that consumer courts across India have consistently upheld, and one that has significant implications for how insurers handle mediclaim rejections.

The commission held that the burden of proving that a claim falls within an exclusion clause rests entirely on the insurer, not the policyholder. Once a valid policy and hospitalisation during the policy period are established, it is the insurer's job to prove exclusion with cogent evidence. Assumptions, circumstantial references to old hospital records, and unsubstantiated allegations of suppression do not meet that standard.

The commission further held that exclusion clauses in insurance contracts must be strictly construed, and any ambiguity must be interpreted in favour of the insured. This is a well-established position in Indian consumer law, and the Thrissur commission applied it directly to knock down National Insurance's repudiation.

This matters beyond this one case. Insurers routinely cite pre-existing disease clauses to reject claims, often without producing the kind of expert medical linkage evidence that courts have repeatedly said is mandatory. Citing a prior ailment in a hospital record is not the same as proving it caused the condition for which a claim is made..

What the Consumer Commission Ordered

The commission allowed the complaint and directed National Insurance Company to pay the following:

Rs 2,00,000 as the admissible insurance claim amount under the policy, along with interest at 9 per cent per annum from 11 February 2013, the date of repudiation, until full realisation. Rs 15,000 as compensation for mental agony and inconvenience. Rs 10,000 towards the cost of proceedings.

The total payout, including the principal, comes to Rs 2,25,000 before interest. Given that the repudiation date is February 2013 and the order was passed in June 2026, the interest component accumulated over more than 13 years will add substantially to the final amount the insurer must pay.

National Insurance has been given one month from the date of receipt of the order to comply. If it fails to do so, the compensation amount will also begin carrying interest at 9 per cent per annum from the date of default until realisation.




Check the case judgement here: