Advocate wins over Rs 4 lakh after health insurer rejects claim | Bengaluru News
Bengaluru: Denied coverage for a major surgery despite holding a health insurance policy, a senior advocate moved a consumer court, which recently directed the insurer to pay him over Rs 4 lakh for rejecting his claim on “unjustifiable grounds”.It all began when Kiran S Javali, 65, bought Tata AIG’s Medicare policy in Feb 2022 after an agent assured him that the plan was specifically designed for senior citizens and did not require pre-policy medical tests. He paid a premium of Rs 84,510, and the new policy took effect from Feb 14, 2022.However, within three months, Javali began experiencing severe pain and difficulty in urination. The Vasanthnagar resident was diagnosed with an enlarged prostate and, for the first time, hypertension. He underwent surgery at Manipal Hospital in May 2022. When Javali applied for a claim for cashless treatment, he was left in shock after it was denied by the insurer. The company cited non-disclosure of pre-existing conditions—specifically LUTS and hypertension—as the reason for the denial. Javali was forced to pay hospital bills amounting to Rs 4 lakh out of his pocket. After the company’s failure to settle his claim, he moved the 2nd Additional District Consumer Disputes Redressal Commission of the city on May 31, 2024, citing a deficiency in service. He also alleged that the Tata AIG agent misled him regarding the benefits of their Medicare policy compared to his previous Max Bupa policy.In its defence, Tata AIG argued that Javali had a history of these health issues for four years, which he allegedly failed to disclose while signing the proposal form. The company cited policy clauses that require full disclosure of material facts, maintaining that the insurance contract operates on the principle of utmost good faith. The insurer also distanced itself from the agent’s verbal assurances, contending that such statements are not binding on the company and that the responsibility to declare medical history lies entirely with the applicant. Tata AIG further pointed out that Javali did not undergo a pre-policy medical examination, which, according to them, should have been a standard requirement given his age.The commission observed that Javali was unaware of his medical conditions at the time of applying for the policy and faulted the insurer for not conducting pre-policy medical tests, despite the complainant being a senior citizen. The commission emphasised the need for transparency in the insurance industry, stating, “The contract of insurance is based on utmost good faith.” The commission held Tata AIG guilty of deficiency in service and unfair trade practices. The commission, on June 10, 2025, ordered the insurer to reimburse Rs 4 lakh with 6% interest from the date of legal notice till realisation, Rs 10,000 in compensation for mental agony and litigation costs. The insurer has been given 45 days to comply, failing which it will have to pay additional interest at the rate of 8% per annum.
