New Delhi. In a significant ruling on insurance claim disputes, the Delhi Consumer Commission has set aside a district forum order that had directed Bajaj Allianz General Insurance to reimburse a mediclaim amount, after concluding that investigation findings revealed serious irregularities in hospital records and supporting documents.
Claim Linked To Hospitalisation
The case involved a health insurance claim of ₹36,847 filed by a policyholder who had been admitted to Prasad Health Care Multispeciality Hospital and Fertility Centre during the policy period from December 30, 2021 to December 29, 2022. The insured was treated for jaundice between November 8 and November 12, 2022 and subsequently sought reimbursement under his policy with a sum insured of ₹3 lakh.
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According to the insurer, the claim was repudiated after verification processes raised concerns about the authenticity of the documents and the insured’s cooperation during the investigation. Bajaj Allianz stated that it faced non-cooperation from the policyholder during verification, which hindered proper assessment of the claim.
The insurer’s repudiation letter further noted that the patient had been hospitalized for investigation and treatment of Acute Viral Hepatitis (Jaundice) with Enteric Fever, but discrepancies were found in the submitted records. The company also cited misrepresentation of facts as a key reason for rejection of the claim.
District Order Challenged
The complainant subsequently approached the district consumer commission, which ruled in his favour and directed the insurer to pay the claim amount along with 9% interest per annum and an additional ₹25,000 as compensation for mental harassment and litigation costs. However, Bajaj Allianz challenged this order before the state-level consumer commission.
During appellate proceedings, the insurer argued that a detailed investigation had revealed multiple inconsistencies in the hospital documentation. The report described the hospital as a “nexus hospital” and flagged concerns including alleged misbehavior with the field investigator, obstruction of verification efforts, and failure to obtain a proper patient statement due to restricted access.
Investigation Report Given Weight
The commission also took note of allegations that the indoor case papers were written in a uniform and stereotyped handwriting, raising doubts about their authenticity. The insurer maintained that such findings clearly indicated manipulation of records and violation of policy conditions requiring full cooperation from the insured during claim verification.
The Delhi Consumer Commission observed that the district commission had failed to adequately consider the investigator’s findings. It held that survey and investigation reports constitute important pieces of evidence in insurance disputes and cannot be ignored without valid reasoning.
Referring to established legal principles, the commission noted that survey reports must be given due weight unless they are proven to be unreliable or based on incorrect facts. It further stated that the complainant failed to produce any credible evidence to substantiate his claim and rebut the insurer’s findings.
No Deficiency In Service Found
In its final order, the commission concluded that the insurer had rightly repudiated the claim in accordance with policy terms and after conducting necessary investigation. It held that no deficiency in service could be attributed to Bajaj Allianz in this case.
With this ruling, the appellate commission not only overturned the district forum’s decision but also reinforced the importance of documentary integrity and cooperation in insurance claims. The judgment is being seen as a reminder of stricter scrutiny in mediclaim disputes, particularly where investigation reports point to possible manipulation of hospital records.
The case highlights the growing role of forensic verification and investigator findings in resolving insurance conflicts, especially in situations involving alleged misrepresentation or irregular documentation.
