Consumer Failed To Rebut Investigator's Findings; Delhi State Commission Sets Aside Mediclaim Reimbursement Order

The Delhi State Consumer Disputes Redressal Commission, comprising Justice Sangita Dhingra Sehgal (President) and Bimla Kumari (Member), allowed the appeal filed by Bajaj Allianz General Insurance Co. Ltd. and set aside the District Commission's order directing reimbursement of a mediclaim amount, holding that the insurer had rightly repudiated the claim on the basis of the investigator's report pointing to non-cooperation and discrepancies in the hospital records.

Case Brief:

The complainant, Mr. Ashok, had purchased an online health insurance policy from Bajaj Allianz General Insurance Co. Ltd. in December 2021 with a sum insured of ₹3 lakh. During the policy period, he was admitted to Prasad Health Care Multispeciality Hospital in November 2022 for treatment of Acute Viral Hepatitis (Jaundice) with Enteric Fever and incurred medical expenses of ₹36,847.

After discharge, the complainant submitted a reimbursement claim before the insurance company for the hospital expenses. However, Bajaj Allianz repudiated the claim alleging non-cooperation during investigation and stating that discrepancies were found in the hospital records. The insurer also relied on an investigator's report claiming that the hospital was a “nexus hospital” and that the patient statement could not be recorded.

Aggrieved by the rejection of his medical claim, the complainant approached the District Consumer Commission alleging deficiency in service and unfair repudiation of the insurance claim. The District Commission allowed the complaint and directed Bajaj Allianz to reimburse ₹36,847 with interest along with ₹25,000 compensation for mental agony and harassment.

Subsequently, Bajaj Allianz challenged the order before the Delhi State Consumer Disputes Redressal Commission.

Contentions  Of Insurance Company

The insurance company contended that the claim was rightly repudiated as the complainant failed to cooperate during investigation, which violated the policy conditions. It relied on the investigator's report stating that discrepancies were found in hospital records, the hospital was allegedly a “nexus hospital,” and the patient's statement could not be recorded. The insurer argued that there was no deficiency in service on its part.

Observations and Decision

The Commission observed that the investigator's report recorded several irregularities during verification of the claim. The report noted that the hospital was a "nexus hospital", the investigator could not record the patient's statement, and the Indoor Case Papers (ICP) appeared to be written in stereotyped handwriting. The Commission observed that both the complainant and the hospital had failed to cooperate with the investigator and had acted in contravention of the policy's Condition Precedent clause.

The Commission reiterated that surveyor and investigator reports constitute important pieces of evidence and cannot be brushed aside unless there is cogent and convincing material to rebut their findings. Relying on precedents of the National Consumer Commission, it held that such reports must be given due consideration unless shown to suffer from non-consideration of material evidence or misrepresentation of facts. Since the complainant failed to place any reliable evidence on record to discredit the investigator's findings, the Commission held that the insurer had validly repudiated the claim in accordance with the policy terms and conditions.

Accordingly, the State Commission allowed the appeal filed by Bajaj Allianz General Insurance Co. Ltd. and set aside the order of the District Consumer Commission directing reimbursement of the claim amount and payment of compensation.

Case No.: FA/240/24

Case Title: Bajaj Allianz General Insurance Co. Ltd. VS Ashok

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