Delhi State Consumer Commission Sets Aside Reimbursement Order, Upholds Mediclaim Repudiation Over Fabricated Hospital Records

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 Company Ltd. and set aside the District Commission's order directing reimbursement of the mediclaim amount, holding that the insurer had rightly repudiated the claim on the basis of the investigator's report pointing to discrepancies and suspected fabrication in the hospital records.

Brief Facts:

Complainant, Pooja Kumari, had purchased an online health insurance policy from Bajaj Allianz General Insurance Company Ltd. for the period between 14-07-2021 and 14-07-2022 with a sum insured of ₹3 lakh. During the policy period, she was admitted to Mahavir Multispeciality Hospital on 01-04-2022 for treatment of Macrocytic Anaemia and remained hospitalized till 05-04-2022. The hospital raised a bill of ₹41,530, which was paid by her.

Subsequently, the complainant lodged a reimbursement claim with the insurance company. However, the insurer repudiated the claim alleging discrepancies in the hospital and pathology records, including fabricated reports and irregularities in serial numbers appearing in records of different patients.

Aggrieved by the repudiation, the complainant approached the District Consumer Disputes Redressal Commission-VI, New Delhi alleging deficiency in service. The District Commission allowed the complaint and directed the insurer to reimburse the claim amount with interest and compensation.

Challenging this order, the insurance company filed an appeal before the Delhi State Consumer Disputes Redressal Commission.

Contentions of the Opposite Party

The insurance company contended that the District Commission erred in allowing the claim despite several discrepancies found in the hospital and medical records submitted by the complainant. It argued that the pathology reports were not verified by the concerned pathologist, identical lab serial numbers appeared in records of different patients, and the hospital records contained fabricated entries. The insurer further submitted that the hospital itself was not approved by DGHS for IPD treatment and that the investigator's report clearly pointed towards fraud and misrepresentation, justifying repudiation of the claim under the policy conditions.

Observations and Decision:

The Commission observed that the investigation report relied upon by Bajaj Allianz General Insurance Company Ltd. disclosed multiple discrepancies in the hospital and medical records submitted by the complainant. The Commission noted allegations that the pathology reports were not verified by the concerned pathologist, identical lab serial numbers appeared in records of different patients, and several entries in the hospital records appeared fabricated. It further found that the complainant had failed to place any cogent material on record to rebut the investigator's findings.

Referring to the fraud and misrepresentation clause contained in the policy, the Commission held that the insurer was entitled to repudiate the claim if fabricated or forged documents were submitted in support of a claim. The Commission also relied on settled precedents holding that surveyor and investigator reports constitute important pieces of evidence and cannot be brushed aside in the absence of convincing material demonstrating non-consideration of relevant evidence or misrepresentation of facts.

The Commission held that the investigator's findings remained unrebutted and that the multiple discrepancies found in the hospital records established a violation of the terms and conditions of the policy, thereby justifying repudiation of the claim.

Holding that the claim was rightly repudiated under the fraud and misrepresentation clause of the policy and that no deficiency in service could be attributed to the insurer, the State Commission allowed the appeal and set aside the District Commission's order.

Case Title: Bajaj Allianz General Insurance Company Ltd. v. Smt. Pooja Kumari

Case No.: First Appeal No. 269/2024

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