NEW DELHI: A Delhi consumer court has upheld an insurer’s decision to reject a health insurance claim after investigators found that a patient’s hospital records showed she received an injection nearly 20 minutes after she had already been discharged — one of ten discrepancies that pointed to suspected fabrication of medical documents.The Delhi State Consumer Disputes Redressal Commission ruled in favour of Bajaj Allianz General Insurance, setting aside an earlier district commission order that had directed the insurer to pay Rs 41,530 to policyholder, along with interest and Rs 25,000 as compensation.What was the dispute about?Pooja Kumari had purchased an online health insurance policy from Bajaj Allianz, which was 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 remained hospitalised from April 1 to April 5, 2022, and the hospital raised a final bill of Rs 41,530, which she paid and then sought to recover from the insurer.The 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 a contradiction in the discharge and treatment records. According to the discharge summary, the patient was discharged on April 5, 2022 at 12:42 PM. Yet 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 flagged this as a “false and fabricated case.”That was not the only red flag. The investigation report listed nine other 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.On top of all this, the investigation revealed that 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.What did the court say?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 has 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 and/or fabricated claim supporting documents are received by the Insurer from insured/representative of insured, to obtain any claim/benefits/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.”
