Delhi consumer commission upholds order on Oriental Insurance to pay heart surgery claim

The Delhi State Consumer Disputes Redressal Commission on 28 October 2026 dismissed an appeal by Oriental Insurance Company and upheld an order directing it to pay a policyholder's rejected heart surgery claim. The insurer must pay Rs 2,70,409 with 6% annual interest from the date the complaint was filed, plus Rs 25,000 as compensation including litigation costs.

What Happened

The policyholder held a Health Shield policy from Oriental Insurance for 5 December 2013 to 4 December 2014, with a sum insured of Rs 5,00,000 and a premium of Rs 9,600. On 30 January 2014 he was admitted with acute coronary syndrome and later underwent bypass surgery at another hospital, being discharged on 13 February 2014.

The insurer rejected his claims, citing exclusion clause 4.1 on pre-existing diseases, because hospital records mentioned diabetes for 10 years and a history of stroke for three years. A district forum in East Delhi ruled for the policyholder on 31 March 2017, and the insurer appealed.

The State Commission held that the burden of proving concealment of a pre-existing disease lies on the insurer. It found the insurer had not shown that the policyholder was earlier hospitalised for diabetes or stroke. It also held that merely mentioning a website in the policy schedule does not prove that the full terms and conditions were supplied to the insured. The commission said an insurer cannot justify rejecting a claim merely by pointing to an exclusion clause without establishing that it applies.

What It Means

For health policyholders, the order restates that a history of common conditions such as diabetes recorded in hospital papers is not, by itself, enough for an insurer to reject a claim; the insurer must prove the clause applies. It also signals that insurers should be able to show the policy terms actually reached the customer.

The order is the State Commission's finding and may be appealed. Policyholders whose health claims are rejected can seek help through the National Consumer Helpline (1915) or file a complaint on e-Daakhil.

Source: Consumer commission order