Bengaluru (Aryavarth): In a significant judgment, the Supreme Court of India has upheld the reimbursement of medical expenses amounting to ₹7,47,638.19 in a long-standing insurance dispute against Reliance General Insurance Co. Ltd. The court’s decision came in response to Civil Appeal Nos. 2769-2770 of 2023, filed by Om Prakash Ahuja against Reliance General Insurance Co. Ltd. and others.
The case involved two revision petitions challenging the orders of the National Consumer Disputes Redressal Commission (NCDRC) and the State Consumer Disputes Redressal Commission. The appellant, Om Prakash Ahuja, had filed a complaint stating that the expenses incurred on his wife’s ovarian cancer treatment were not reimbursed by Reliance General Insurance Co. Ltd. despite having a valid health insurance policy.
The appellant argued that he had purchased a health insurance policy for his family, which was valid from July 7, 2007, to July 6, 2008. The policy was subsequently renewed until July 6, 2009. However, the insurance company repudiated the claim, alleging that the appellant’s wife had a pre-existing condition of rheumatic heart disease that was not disclosed in the proposal form.
The District Consumer Disputes Redressal Forum directed Reliance General Insurance Co. Ltd. to reimburse the expenses incurred by the appellant on his wife’s treatment, along with interest at 8% per annum. It also found the refusal to renew the insurance policy to be arbitrary and ordered its renewal upon payment of the premium. The State Commission upheld this order, which was further challenged by Reliance General Insurance Co. Ltd. before the NCDRC.
The NCDRC, in its order dated November 26, 2018, upheld the reimbursement of expenses amounting to ₹7,47,638.19 incurred on the treatment but set aside the direction for renewal of the health insurance policy. Reliance General Insurance Co. Ltd. then filed a revision petition challenging this order.
During the proceedings, the appellant’s counsel argued that the expenses incurred on the treatment of his wife should be reimbursed as there was no dispute regarding the actual expenses. The concealment of rheumatic heart disease, he contended, had no relation to the ovarian cancer for which the treatment was sought. The counsel relied on a previous Supreme Court judgment, Sulbha Prakash Motegaonkar v. LIC, to support his argument.
On the other hand, Reliance General Insurance Co. Ltd.’s counsel argued that the appellant could not benefit from an order that had been set aside. The company contended that the policy renewal beyond July 6, 2009, was not proper, and therefore, no claim was admissible.
After considering the arguments, the Supreme Court held that the expenses amounting to ₹7,47,638.19 incurred during the period from July 7, 2007, to July 6, 2009, should be reimbursed to the appellant by Reliance General Insurance Co. Ltd. The court agreed that the concealment of rheumatic heart disease did not have any bearing on the treatment for ovarian cancer. However, the court concurred with the NCDRC’s decision to set aside the direction for policy renewal, stating that Reliance General Insurance Co. Ltd.’s non-renewal of the policy had deprived the appellant of seeking coverage from another company.
The court emphasized that it would be unjust to deny the appellant the benefits of the policy despite Reliance General Insurance Co. Ltd. charging a higher premium to cover the extra risk associated with the renewal. The Supreme Court upheld the reimbursement of medical expenses amounting to ₹7,47,638.19 for the specified period and dismissed Reliance General Insurance Co. Ltd.’s revision petition.
This judgment sets an important precedent in insurance disputes, clarifying that Reliance General Insurance Co. Ltd. is liable to reimburse the incurred medical expenses. The court’s decision reaffirms the principle of consumer protection and fair treatment of policyholders in the health insurance sector.
