5 min readNew DelhiJul 23, 2026 05:30 PM IST
Noting that in order to maintain the faith and confidence of the common man in the insurance sector, the insurance companies are expected to act fairly, ethically, and responsibly, the District Consumer Commission, Ropar, directed an insurer to reimburse Rs 90,079 spent on a policyholder’s son’s dengue treatment.
A bench of president Kuljit Pal Singh and members Ranvir Kaur and Ramesh Kumar Gupta also awarded Rs 10,000 compensation for mental agony and Rs 11,000 towards litigation costs.
“It is also necessary to observe that the very purpose of health insurance is to provide financial security and timely assistance to the insured person at the time of medical exigency. In order to maintain the faith and confidence of the common man in the insurance sector, the insurance companies are expected to act fairly, ethically, and responsibly while processing genuine claims of the insured persons,” said the July 2 order.
Pointing out that the repudiation of the claim by the opposite party is primarily based upon certain alleged discrepancies noticed in the medical records, the order remarked that, however, such discrepancies, by themselves, cannot be treated as conclusive proof of a false or fraudulent claim.
It is a matter of common understanding that medical records are prepared by hospital staff, doctors and other healthcare professionals, and the insured person has no direct control over the manner, timing or technical recording of such entries, it observed.
Dengue claim rejected over technicalities
A patient approaching a hospital in a medical emergency places reliance upon the treating doctors and hospital authorities and cannot be expected to supervise each and every administrative or technical entry made in the treatment records.
A man purchased a Future Health Suraksha, Family Floater Insurance Policy covering himself, his wife, and his son after paying a premium of Rs 19,404 for the period June 30, 2021 to June 29, 2022. During the policy period, his son was hospitalised with dengue fever from October 1 to October 9, 2021, at Kaushal Multi-Speciality Hospital, Kharar.
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The complainant incurred Rs 90,079 towards treatment and sought reimbursement from the insurer. However, the insurance company rejected the claim, citing discrepancies in medical records, including differences in treatment timings, Google Timeline data, and missing clarifications from the hospital.
Alleging that the repudiation was arbitrary and amounted to a deficiency in service and unfair trade practice, he approached the commission seeking reimbursement, compensation for mental agony, and litigation costs.
The insurer did not file its written statement within the statutory period and was proceeded ex parte. Although it later attempted to submit a written version, the commission rejected it as time-barred.
However, in its claim denial letter, the insurer maintained that the claim was inadmissible because it found discrepancies during verification, including inconsistencies between the patient’s Google Timeline and the claimed hospitalisation, differences in admission and vital-record timings, lack of clarification from the pathologist regarding laboratory reports and digital signatures, and inconsistencies in the TPR charts.
Patients can’t control medical records
The commission held that the insurance broker was only a facilitator and had no role in underwriting the policy or deciding the claim. Since the broker neither issued the policy nor repudiated the claim, no deficiency in service could be attributed to it.
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The commission emphasised that the purpose of health insurance is to provide financial protection during medical emergencies. Insurance companies are expected to deal with genuine claims fairly and cannot reject them merely on technical or procedural grounds.
It observed that minor discrepancies in hospital records, such as differences in timings or documentation prepared by hospital staff, cannot by themselves prove fraud. Patients have no control over the preparation of medical records, and such inconsistencies cannot be the sole basis for denying a genuine claim.
The commission held that the burden of proving fraud, fabrication, or suppression of material facts lies on the insurer. In this case, the insurer failed to produce any cogent evidence, such as testimony from the investigator, expert opinion, or independent witnesses, to establish that the hospitalisation or medical records were fraudulent.
The commission directed the insurer to reimburse Rs 90,079 with 9 per cent annual interest from January 24, 2022, pay Rs 10,000 as compensation for mental agony and Rs 11,000 towards litigation costs. The complaint against the insurance broker was dismissed.
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Takeaway
This ruling reinforces that insurers cannot reject genuine health insurance claims based on minor discrepancies in hospital records without proving fraud through credible evidence. It also clarifies that patients cannot be held responsible for administrative errors made by hospitals, strengthening consumer protection against arbitrary claim repudiation.
Consumers facing similar grievances may contact the consumer helpline in their respective states (Punjab helpline: 1800-425-1082) or dial the National Consumer Helpline at 1915 for assistance.
