The Delhi State Consumer Disputes Redressal Commission has upheld the decision of Bajaj Allianz General Insurance to reject a health insurance claim after an investigation revealed multiple inconsistencies in medical records, including the administration of an injection nearly 20 minutes after the patient had been discharged. The commission set aside an earlier district commission order that had directed the insurer to pay Rs 41,530 along with interest and Rs 25,000 as compensation.
Details of the Case
Pooja Kumari had purchased an online health insurance policy from Bajaj Allianz, valid from July 14, 2021 to July 14, 2022, with a sum insured of Rs 3 lakh. In April 2022, she was admitted to Mahavir Multispeciality Hospital in New Delhi for treatment of Macrocytic Anaemia. She was hospitalized from April 1 to April 5, 2022, and the hospital raised a final bill of Rs 41,530, which she paid and then sought reimbursement from the insurer.
Bajaj Allianz rejected the claim in July 2022 after its investigation agency, Aizon Healthcare Services, visited the hospital and flagged a series of inconsistencies in the medical records. The most striking finding was that the discharge summary indicated the patient was discharged on April 5, 2022 at 12:42 PM, but the inpatient case papers showed that her vitals were recorded and an injection was administered at 1:00 PM the same day — nearly 20 minutes after she had supposedly left the hospital. The investigator termed this a false and fabricated case.
Other Discrepancies Found
The investigation report listed nine additional discrepancies, including:
- The pathologist named on the lab reports, Dr K.D. Gandhi (MD Pathology), confirmed in writing that the reports submitted in the patient's name were not verified by him, stating that this report was not verified by me.
- The symptoms recorded in the inpatient case papers differed from what the patient herself stated during the investigation — the records noted low grade fever, tiredness and body ache, while the patient described high fever, vomiting and abdominal pain.
- The patient stated that tablets and syrup were not prescribed post-discharge, which contradicted both the nursing records and the discharge card.
- Mahavir Multispeciality Hospital was not registered under DGHS for inpatient treatment. The hospital had applied for registration in May 2021, but the application remained on hold at the time of the claim.
Court's Ruling
The commission paid particular attention to Dr K.D. Gandhi's written denial. The bench, comprising Justice Sangita Dhingra Sehgal (President) and Bimla Kumari (Member), observed that the district commission had committed a glaring error in concluding that the patient had been treated under Dr Gandhi's supervision, when Dr K.D. Gandhi himself denied the same. The commission referred to the fraud clause in the standard terms and conditions of the Bajaj Allianz policy, which states that if any fraudulent means or devices are used or forged or fabricated claim supporting documents are received by the Insurer from the insured or representative of the insured to obtain any claim, benefits, or indemnities under the policy, all benefits under the policy shall be void and all claims or payments thereunder shall be forfeited.
Applying this clause to the facts, the commission held that the insurer had valid grounds to repudiate the claim. Setting aside the district commission's order, the state commission concluded that the claim was rightly 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.
