Insurance company ‘rejects’ son’s dengue hospitalisation claim, mother wins Rs 26,882

The order stated that in our considered opinion, the claim of the complainant for the reimbursement of the medical expenses incurred on his treatment is genuine and payable by the Opposite Party-Insurance Company. By rejecting the genuine claim of the complainant, the opposite parties are found deficient.

Dengue claim wrongfully rejected by insurer

The complainant had been continuously covered under Star Health’s Family Health Optima Insurance Plan since November 2020, which insured her and her two children.

During the policy period from November 23, 2024 to November 22, 2025, her son was hospitalised for dengue from November 1 to November 2025 at Dhaliwal Child Care Centre, Moga. Although she sought cashless treatment, the insurer’s officials advised her to pay the hospital expenses herself as approval would take time. She paid Rs. 22,751 and later submitted a reimbursement claim.

However, the insurer repudiated the claim on the ground of alleged “misrepresentation of facts” due to discrepancies in the medical records. Aggrieved by the rejection despite renewing the policy for another year, she approached the district consumer commission alleging deficiency in service and seeking reimbursement, compensation, and litigation costs.

Insurer alleged medical record discrepancies

The insurer argued that the complainant had accepted the policy terms and conditions while purchasing the insurance policy covering herself and her dependent children for Rs. 10 lakh.

It submitted that, upon assessment of the reimbursement claim, its medical team found discrepancies in the medical records amounting to misrepresentation of facts. The insurer further alleged that the medical records were deficient because the hospital had not maintained vital charts, initial assessment sheets, progress notes, intake-output charts, proper payment receipts, or the patient’s UHID/IPD number on the discharge summary. It also questioned whether a five-day hospitalisation was medically justified.

Without prejudice to its defence, the insurer argued that even if it were held liable, its maximum liability under the policy would be Rs. 21,882, not the entire amount claimed by the complainant.

Hospital records beyond consumer’s control: Order

The commission observed that it was undisputed that the complainant had a valid Family Health Optima Insurance Policy covering herself and her two children, and that her son was hospitalised for dengue during the policy period. It also noted that the insurer had repudiated the reimbursement claim solely on the ground of alleged “misrepresentation of facts.”

It found that the additional discrepancies cited by the insurer in its written statement, such as the absence of vital charts, progress notes, intake-output charts, proper payment receipts, and UHID/IPD details, were not mentioned in the repudiation letter. These records were prepared and maintained by the hospital and were beyond the complainant’s control.

The commission further held that the insurer had made no effort to verify the alleged discrepancies with the treating hospital before rejecting the claim. In the absence of any evidence establishing fraud or mala fide conduct by the complainant, the insurer failed to prove that there had been any misrepresentation.

Takeaway

This judgment reinforces that insurers cannot reject genuine health insurance claims based on vague allegations or deficiencies in hospital records that are beyond the insured’s control. It emphasizes that insurers must properly verify discrepancies before repudiating claims, ensuring greater accountability, fairness, and protection for policyholders under consumer protection law.

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.