New Delhi, Oct 16 A Delhi consumer commission has held Niva Bupa Health Insurance Company Ltd liable for deficiency in service for rejecting a 76-year-old woman's medical reimbursement claim after repeatedly seeking documents over an erroneous entry in her hospital records.
The District Consumer Disputes Redressal Commission-VIII, comprising President Divya Jyoti Jaipuriar and Member Rashmi Bansal, directed the insurer to reimburse Rs 3.87 lakh spent on hospital treatment, pay Rs 50,000 as compensation for mental agony and harassment and Rs 35,000 towards litigation expenses.
In an order dated September 24, the commission said, "The complainant was required to undergo prolonged correspondence with the Opposite Party and repeatedly furnish documents and clarifications in respect of her medical claim. Despite the documents and medical clarification being placed before the Opposite Party, her claim was ultimately rejected."
The commission ordered payment of six per cent annual interest on the reimbursement amount from April 25, 2024 until realisation. The insurer has been given 45 days from receipt of the order to comply.
The complainant, Madhu Sawhney, had purchased two health insurance policies under the Platinum variant from Niva Bupa in June 2023 with sums insured of Rs 10 lakh and Rs 25 lakh.
She said she had disclosed her pre-existing conditions, including diabetes, lipid disorders and hypertension when taking the policies. The insurer had also conducted a pre-policy medical examination.
Sawhney was admitted to the emergency department of Max Super Speciality Hospital in Shalimar Bagh on December 23, 2023. The initial assessment mistakenly recorded chronic kidney disease (CKD), but the entry was corrected through an addendum on December 30, during the same hospital stay and before her discharge.
The insurer declined cashless authorisation, citing inadequate documents, forcing her to pay the hospital bill herself. It subsequently sought further medical records and clarifications between January and April 2024, including an affidavit from the treating doctor regarding the CKD entry.
The reimbursement claim was rejected on April 25, 2024, for non-submission of mandatory documents.
The commission noted that the hospital had corrected the entry and the treating doctor had clarified that Sawhney had no history of renal dysfunction and her kidney function tests were normal.
It observed that insurers could seek relevant documents but could not repeatedly demand material already supplied or documents that were not reasonably obtainable, leaving claims pending indefinitely.
As Niva Bupa failed to file its written version within the statutory period, its right to do so was closed by an order dated May 29, 2025.
In case of default in payment, interest on the reimbursement amount will rise to nine per cent per annum from April 25, 2024, until realisation.
