SBI Insurance Told To Pay Rs 1.47 Lakh

The case was filed by G. Durga Rani, a homemaker from Miyapur, on behalf of her son Mokshi Naga Venkat Sai, who was born in April 2016. The child had been included under a family health insurance policy taken in 2015. He was hospitalised twice in 2017, incurring medical expenses of Rs 49,683 and Rs 97,660.

The insurance company rejected both claims, citing two reasons: that the child was covered only for the first 90 days after birth and that further coverage would apply only after renewal and that the child had a pre-existing condition—tuberculosis from birth. The insurer also alleged that documents for the second hospitalisation were not submitted.

However, the commission, comprising in-charge president Meena Ramanathan and member V.V. Seshubabu, dismissed the insurer’s arguments after examining the policy terms and timeline. They found that the child’s first hospitalisation occurred in August 2017—when he was 1 year and 4 months old—and the second in October 2017. Both events fell outside the one-year waiting period and the initial 30-day exclusion clause, making the insurer’s rejection baseless.

The commission also rejected the claim of a pre-existing condition, stating that such an allegation was implausible for a baby. “Suppression of medical condition and concealment of history cannot be accepted by this Commission since the complainant, Mokshi Naga Venkat Sai, is a very young child—a baby/toddler—and his health condition is only known for the first time,” the order stated.

It also found that the complainant had submitted all required documents for both claims, contrary to the insurance company’s claims. Apart from directing SBI General Insurance to pay the total claim amount of Rs 1.47 lakh, the commission also ordered the insurer to pay Rs 20,000 as compensation and Rs 10,000 towards legal costs.