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Rs 18.7 Lakh Payout Ordered After Insurer Rejects Transplant
21 Oct
Summary
- Insurance company ordered to pay Rs 18.7 lakh plus interest and compensation.
- Insurer denied cashless treatment for liver transplant citing alcoholism.
- Consumer commission ruled the exclusion clause did not apply to the case.
A Chandigarh consumer commission has mandated an insurance firm to disburse Rs 18.7 lakh, plus interest and compensation, to a Mohali resident. The insurer had previously denied cashless treatment for a critical liver transplant, citing a policy exclusion for alcoholism.
The commission found that the insurer could not substantiate its claim that the transplant and subsequent hospitalizations were for an excluded condition. Despite the policy containing exclusions for alcoholism and its consequences, the insurer failed to prove the patient had received prior treatment for such conditions.
The man, covered under a policy since 2018, was diagnosed with alcoholic liver disease in November 2023. His wife donated part of her liver for a transplant in October 2024, incurring Rs 15.17 lakh in bills, all of which were denied by the insurer.
Subsequent hospitalizations for post-transplant complications in 2024 and 2025 were also rejected. The commission's order emphasizes that insurers must prove an exclusion applies, rather than merely linking a treatment to an excluded condition, especially when a diagnosis is recent.
