Bajaj Allianz wins mediclaim dispute after investigator finds hospital records were manipulated

NEW DELHI: The Delhi consumer court has set aside an order directing reimbursement of a mediclaim amount, holding that an insurer was justified in repudiating the claim after an investigation revealed multiple flaws and discrepancies in the hospital records.A bench comprising Justice Sangita Dhingra Sehgal (President) and Bimla Kumari (Member) allowed the appeal filed by Bajaj Allianz General Insurance against a district commission order that had earlier directed the insurer to pay the claim amount along with compensation to the insured consumer.What was the insurance claim dispute aboutThe complainant, Ashok, had purchased a health insurance policy from Bajaj Allianz valid from December 30, 2021 to December 29, 2022, with a sum insured of Rs 3 lakh. During the policy period, he was admitted to Prasad Health Care Multispeciality Hospital and Fertility Centre on November 8, 2022 for the treatment of Jaundice and remained hospitalised till November 12, 2022.The hospital generated a final bill of Rs 36,847, which the complainant paid.However, he then sought reimbursement under the policy which the insurer repudiated, citing non-cooperation of the insured for verification and misrepresentation of facts.The repudiation letter stated that the “verification of claim documents reveal aforesaid claimant was hospitalized for investigation and treatment of Acute Viral Hepatitis (Jaundice) with Enteric Fever and is claiming for expenses incurred of Rs 36,847. We have faced non-cooperation from insured for verification of claim. Hence, we regret to inform that your claim stands repudiated in view of misrepresentation of facts.“Aggrieved by the claim rejection, the complainant approached the district consumer commission, which ruled in his favour and directed Bajaj Allianz to pay Rs 36,847 with interest at 9 per cent per annum from the date of filing of the claim, along with Rs 25,000 as compensation for mental agony and harassment. The insurer then challenged that order before the state commission.What was the reason for rejecting the claimAccording to the insurer, the investigation uncovered several discrepancies in the medical documents submitted by the complainant.The investigation report noted that the hospital was a “nexus hospital,” that hospital staff misbehaved with the field officer during the visit, that the field officer’s phone was retained by nexus persons preventing a patient statement from being recorded, and that the entire Indoor Case Paper was written in stereotyped handwriting.The insurer further argued that the complainant and the hospital had violated a key condition of the insurance policy, which states that the insured must fully cooperate with and fulfil all policy requirements before the company is obligated to pay any claim.Delhi consumer commission observationsThe state commission observed that the district commission had failed to take note of the investigator’s findings, which it said was “contrary to the established position of law that Survey Report must be given consideration.”Relying on principles that investigator and surveyor reports constitute important evidence, the commission noted that it is “an established legal position that survey reports need due consideration, unless the report reveals non-consideration of material evidence or misrepresentation of facts.” the commission further noted that the respondent had failed to produce any reliable evidence to support his claim.The commission concluded that the claim was rightly repudiated and that “no deficiency of service can be carved out on the part of the Appellant.”“We opine that the claim was repudiated by the Appellant as per the terms and conditions of the policy, after getting the necessary Investigation done and no deficiency of service can be carved out on the part of the Appellant,” the commission said.