Mumbai: Consumer Commission Rejects Insurance Claim As Paralytic Stroke Not Classified As 'Critical Illness'

The South Mumbai District Consumer Dispute Redressal Commission has dismissed a plea filed by a Wadala-based insurance agent, Umesh Mehta, after his paralytic stroke was not recognised under the list of critical illnesses covered by his insurance policy. The commission clarified that while Mehta’s illness and treatment were genuine and significant, they did not meet the criteria for a claim under the critical illness category.

Umesh Mehta, a senior citizen, had purchased a critical illness insurance policy from the National Insurance Company limited, for a sum assured of ₹10 lakhs for the period 2017–2018. On April 7, 2018, he suffered a paralytic stroke, clinically diagnosed as Critical Venous Thrombosis with Perital Venous Infarct. Mehta was hospitalized for seven days at Shushrusha Citizens’ Co-op. Hospital Ltd., Dadar, and subsequently discharged.

In June 2018, Mehta filed a claim under his critical illness policy, asserting that the stroke he had suffered qualified as a critical illness. While the National Insurance Company reimbursed his hospitalization expenses, it rejected his ₹10 lakh claim under the critical illness cover. Aggrieved, Mehta approached the consumer commission for relief.

Insurance Company’s in its defence had argued that Mehta held two policies—a mediclaim policy and a critical illness policy. While the hospitalization expenses were cleared under the mediclaim policy, the critical illness claim was denied because the medical condition did not fall under the defined terms of critical illness in the policy.