insurance company
A software engineer, who lost his mother in a violent attack and spent over Rs 10 lakh on the treatment of his seriously injured father, was denied a claim by health insurance company HDFC ERGO General Insurance. The company claimed that the patient had a long history of alcohol consumption. However, the son challenged this decision legally and ultimately won from the Consumer Commission. District Consumer Disputes Redressal Commission has ordered the insurance company to pay Rs 6 lakh along with interest. The Commission said that the decision to reject the claim was not appropriate.
What was the whole matter?
A software engineer hailing from Andhra Pradesh had taken a health insurance policy of HDFC ERGO for his father since 2019. This policy was valid from March 25, 2024 to March 24, 2025 and a premium of Rs 42,750 was paid for it.
On June 25, 2024, the complainant’s parents were allegedly attacked with knives and iron rods by some relatives and other people. His mother died in this attack, while his father was seriously injured.
First he was treated in a government hospital, later he was admitted to Continental Hospitals, Hyderabad. He was also kept in ICU during treatment. About Rs 10.17 lakh was spent on the total treatment.
Why did the insurance company reject the claim?
The controversy started when the hospital’s discharge summary mentioned “Alcohol Withdrawal Psychosis”, i.e. the mental condition related to quitting alcohol. On the basis of this, the insurance company claimed that the patient had hidden his history of drinking alcohol. For this reason the company rejected the claim and also canceled the policy.
However, the family clarified that the father never drank alcohol. Later, the treating doctor and the hospital also stated in writing that the patient’s state of confusion and lethargy was not due to alcohol but due to severe kidney disease, anemia and physical and mental trauma caused by the attack. The hospital later amended the discharge summary and removed the controversial comment.
What did the commission say?
The consumer commission found that the insurance company rejected the claim only on the basis of the initial discharge summary, even though both the hospital and the doctor had later given written explanations. The Commission termed the attitude of the insurance company as arbitrary, unfair and deficient in service. The hospital was also held guilty of negligence because such comments were recorded without adequate verification.
What did the family get?
The Commission ordered HDFC ERGO to repay the medical claim of Rs 6 lakh with 9% annual interest. Apart from this, Continental Hospitals was directed to pay Rs 1 lakh for mental agony and Rs 25,000 as litigation expenses.
Experts say that this decision shows that insurance companies cannot reject claims merely on the basis of guesswork. If the policyholder has the correct documents and medical records, a wrongfully rejected claim can be legally challenged.
