Punjab consumer commission upholds order against Oriental Insurance on rejected mediclaim

The State Consumer Disputes Redressal Commission, Punjab, has dismissed an appeal by The Oriental Insurance Company Limited and upheld an order directing it to pay a policyholder's hospital bill of Rs 2,52,400. In its order of 15 October 2026, the commission held that the insurer wrongly rejected the claim on the ground of a pre-existing disease.

What Happened

According to the order, a policyholder from Kapurthala held a PNB-Oriental group mediclaim policy, meant for Punjab National Bank account holders, from May 2017. The policy was not renewed on its due date in May 2019 and was renewed only on 27 August 2019, after a gap of about three months. In June 2020 the policyholder was hospitalised for peripheral arterial disease, a blockage of leg arteries, and underwent angioplasty and stenting. The insurer rejected the claim, saying the disease was pre-existing and excluded for three years.

The commission held that, because of the break and with no endorsement recording continuity, the policy from 27 August 2019 was a fresh policy.

But the commission held that the insurer still had to prove, with cogent evidence, that the disease existed before that fresh policy began. Per the order, the insurer relied only on the discharge summary of the 2020 treatment, which noted a past history of diabetes and hypertension. It produced no earlier treatment records or proposal form. The commission held that such a history note, without supporting evidence, could not justify rejecting the claim, and that diabetes and hypertension are lifestyle conditions whose non-disclosure did not amount to suppression in this case.

What It Means

The district commission had ordered the insurer to pay Rs 2,52,400 with 6% annual interest from the date of hospitalisation, plus Rs 10,000 as cost and compensation, within 45 days. That order now stands. The Rs 1,53,916 the insurer deposited when appealing will be released to the policyholder after 45 days from receipt of the certified copy.

The order shows that a renewal break can restart waiting periods, and that an insurer rejecting a claim as pre-existing must prove it. The order is the commission's finding and may be appealed. Consumers can seek help through the National Consumer Helpline (1915) or file complaints on e-Daakhil.

Source: Consumer commission order