Care Health Insurance rejected heart attack patient's mediclaim over ‘pre-existing diabetes, hypertension’: Court says these are ‘lifestyle diseases’; orders insurer to pay Rs 2.1 lakh

Care Health Insurance has been ordered to pay Rs 2.1 lakh to a Delhi policyholder after a consumer commission ruled that rejecting his heart attack mediclaim on grounds of pre-existing diabetes and hypertension was both unfair and unsupported by evidence.

The order was passed on 7 August 2026 by the District Consumer Disputes Redressal Commission, West Delhi, comprising President Sonica Mehrotra and Members Richa Jindal and Anil Kumar Koushal.

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What happened with the mediclaim?

The complainant held a health insurance policy with Care Health Insurance, originally taken in 2018 and renewed for Rs 5 lakh coverage for 2019 to 2020. In April 2019, he was admitted to Manipal Hospital after suffering a myocardial infarction. He was diagnosed with acute lateral wall MI and coronary artery disease, and underwent angioplasty with stenting.

He filed a claim of Rs 1,93,234 with Care Health Insurance. The insurer rejected both the cashless claim and the final reimbursement claim, citing pre-existing Type 2 diabetes and hypertension as grounds for repudiation.

Did Care Health Insurance prove pre-existing diabetes and hypertension?

The commission found that Care Health Insurance relied on a single-page document of medical history, marked as Exhibit OPW1/3, which carried no name of the complainant, no name of any treating doctor, and no hospital identification. The commission noted the document was unverified, unstamped, and unsigned.

The insurer also relied on progress notes and an assessment sheet from Orchid Hospital dated April 2019, where the complainant had been admitted separately for an unrelated condition, which recorded him as a known case of diabetes since one year and hypertension since three years.

Against this, the complainant produced his discharge summary from Orchid Hospital for the same admission, which recorded no past history of hypertension or diabetes. He also produced a certificate from Manipal Hospital's operating surgeon Dr. Rajesh, dated 24 April 2019, which stated clearly that the complainant was normotensive and non-diabetic at the time of his heart surgery, and that his coronary artery disease was diagnosed only after the angiogram.

Critically, the commission noted that Care Health Insurance did not examine a single doctor from Orchid Hospital to substantiate its claim that the complainant had pre-existing conditions. The commission held that mere progress notes recorded in a hospital, without the doctor who recorded them being examined, do not constitute substantive evidence.

Are diabetes and hypertension grounds to reject a mediclaim?

This is where the commission's order carries weight beyond this individual case. The bench relied on a line of rulings from the National Consumer Disputes Redressal Commission and the Delhi State Consumer Commission that have consistently held that diabetes and hypertension cannot be treated as chronic or fatal diseases justifying mediclaim rejection.

The NCDRC, in Satish Chandra Madan versus Bajaj Allianz General Insurance, held that hypertension is a common medical complaint and not a disease, and that it can be controlled by medication. In Satender Singh versus National Insurance Company, the NCDRC held that merely recording a patient's history does not make it substantive evidence when the doctor recording it has not been examined.

Most directly, the NCDRC in Sahara India Real Estate Corporation versus D.K. Tiwari, decided in April 2022, held that diabetes and hypertension are lifestyle diseases and not chronic or fatal diseases, and that rejecting a claim on these grounds is unfair. The same position was reaffirmed as recently as March 2025, when the NCDRC in PNB MetLife Insurance versus Mrs. Binapani Biswas held that an insurer which fails to place on record proof of medications prescribed or taken for alleged pre-existing conditions, and fails to examine any doctor, has not discharged its burden of proof.

Applying these rulings, the West Delhi commission held that Care Health Insurance's rejection of the complainant's claim was unfair and that the insurer had failed to prove its own allegation.

What did the court order Care Health Insurance to pay?

The commission directed Care Health Insurance to pay the full claim amount of Rs 1,93,234 with interest at 6 per cent per annum from the date of filing the complaint until realisation. It also ordered Rs 25,000 as compensation for mental and physical harassment, inclusive of litigation costs, bringing the total payout to approximately Rs 2.18 lakh.

The insurer has been given 30 days from receipt of the order to comply.

Check the case judgement here: