Surat: The Surat District Consumer Disputes Redressal Commission (Additional) ordered an insurer to reimburse a policyholder’s medical claim after finding that it relied solely on a doctor’s certificate to classify an illness as a skin disorder covered by a waiting-period exclusion.The case involved a man who had bought a health insurance policy from The New India Assurance Company Ltd for the period from March 29, 2019, to March 28, 2020.During the policy term, the complainant’s son was diagnosed with cellulitis with sepsis in his right leg and was admitted to hospital from Jan 30 to Feb 3, 2020. The treatment cost Rs 36,374, and the policyholder later sought reimbursement from the insurer.The company rejected the claim on March 14, 2020, citing clause 4.3.1 of the policy terms, which prescribed a 24-month waiting period for specific conditions including skin disorders.The policyholder challenged the decision before the consumer commission, seeking reimbursement of expenses along with interest, compensation for mental agony and litigation costs.The insurer maintained that the claim had been rejected in accordance with policy conditions and that there had been no deficiency in service.After examining the records and submissions, the commission found that the insurer had relied on a doctor’s certificate dated March 1, 2020, to support its decision. It had produced no investigation report or other medical evidence to establish that the illness qualified as a skin disorder under the exclusion clause.The commission noted that cellulitis with sepsis is a serious skin infection. It held that the doctor’s certificate alone could not conclusively establish that the patient suffered from a skin disorder.Holding that the claim was rejected without adequate supporting evidence, the commission found the insurer deficient in service.In an order pronounced on Oct 16, 2026, the commission partly allowed the complaint and directed the insurer to pay Rs 36,374 with simple interest at 7% a year from Feb 17, 2021, until payment. It also awarded Rs 3,000 as compensation for mental agony and harassment and Rs 2,000 towards litigation costs.
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