Mumbai District Consumer Commission Allows Medical Insurance Claim; Holds Repudiation Illegal

Consumer Rights Upheld | Victory for Policyholders 

We are pleased to share a recent success secured by Kumar Legal Research LLP before the District Consumer Disputes Redressal Commission, Mumbai Suburban, in Complaint Case No. CC/227/2022.

Case Summary:
Our client filed a complaint against SBI General Insurance Co. Ltd., challenging the unfair repudiation of a medical insurance claim worth ₹13.43 lakhs following his hospitalization and bypass surgery.

Despite declaring his pre-existing conditions at the time of policy inception, the insurer rejected the claim citing a special exclusion clause—allegedly added later without his knowledge.

The Commission’s Findings:
The insurer failed to prove the existence of the exclusion clause in the original policy.It did not communicate any change in terms to the complainant transparently.The medical condition could not be conclusively linked to pre-existing illnesses.The act amounted to deficient service and unfair trade practice.

Final Order:
The Commission directed SBI General Insurance to:
Pay the claim amount alongwith 6% interest from the date of repudiation,
Pay ₹1,00,000 as compensation, Pay ₹10,000 towards litigation costs,

This decision reinforces the importance of transparency in insurance contracts and the consumer’s right to fair treatment under the Consumer Protection Act.

Special appreciation to our dedicated team, particularly Govind Javeri and Kirti Choubey for their outstanding legal research, drafting, and courtroom strategy.

At Kumar Legal Research LLP, we remain committed to championing the rights of individuals against institutional injustice.