Covid Claim Denied Fake Documents Man Wins Rs 2 5 Lakh Insurer

Underscoring that insurers are expected to demonstrate a high degree of fairness and good faith while dealing with health insurance claims, a Haryana district consumer commission has directed Star Health and Allied Insurance Co Ltd to pay the claim amount of Rs 2.50 lakh to a man under its Corona Rakshak Policy.

Observing that branding genuine medical documents as fake without conclusive proof and arbitrary repudiation of valid insurance claims strikes at the very object of mediclaim insurance, a bench of presiding member Manjit Singh Naryal of the Charkhi Dadri district consumer commission also ordered the company to pay Rs 10,000 as compensation and Rs 10,000 as litigation cost.

“Insurance companies are expected to act with utmost fairness and good faith while dealing with health insurance claims, especially during the COVID-19 pandemic, situations affecting public health and human lives. In the present case, despite the existence of an authentic RTPCR report, hospitalisation records, and corroborative claim settlement by another insurer, the opposite parties chose to repudiate the claim on speculative and unsubstantiated allegations,” the commission’s order dated June 3 held.

The complainant obtained a Corona Rakshak Policy from Star Health and Allied Insurance Co Ltd for a sum insured of Rs 2.50 lakh for the relevant policy period, after paying the requisite premium and fulfilling all formalities within the jurisdiction of Charkhi Dadri district.

During the subsistence of the said policy, on developing symptoms of Covid-19, the complainant got himself tested from a government-authorised diagnostic centre, i.e. Dr Lal Path Labs, where his RTPCR test report showed that he was Covid-positive.

The complainant duly incurred medical expenses and also received treatment under a health insurance scheme, and thereafter lodged his genuine claim with the opposite party by submitting all necessary documents, including RTPCR report, hospital records, discharge summary and other requisite papers strictly in compliance with the policy conditions.

However, according to the complainant, the opposite parties, after an inordinate and unexplained delay, arbitrarily and illegally repudiated the genuine claim of the complainant vide repudiation letter, on wholly false, baseless and preposterous allegations of misrepresentation of facts and submission of fake documents, merely with a mala fide intention to deny the legitimate claim amount.

Star Health Allied Insurance Co Limited filed a written statement and raised preliminary objections, inter alia, that the present complaint is not maintainable, there is no deficiency in service on their part, the complainant has no locus standi or cause of action, and that the complaint is based on false and fabricated facts and suppression of material facts.

The insured argued that the claim about hospitalisation from February 13, 2023, to February 19, 2023, at Gemini Heart Care Hospital was repudiated on account of serious discrepancies such as indoor patient records being written in a single handwriting, bills issued without GST, operation of two hospitals in the same premises with the same doctor and nursing staff, inadequate hospital infrastructure, etc.

It also alleged doubtful medical documentation and an apparent nexus between the insured and hospital, along with delay in intimation beyond the stipulated period as per policy conditions.

This judgment is significant because it protects consumers from arbitrary claim repudiations based on mere suspicion rather than legal proof. It establishes that technical delays cannot defeat substantive rights. Furthermore, it affirms that benefit-based policies must be honoured once eligibility, like Covid-positivity and hospitalisation, is established.

Consumers facing similar grievances may contact the consumer helpline in their respective states (Haryana contact: 1800-180-2087) or dial the National Consumer Helpline at 1915 for assistance.

Jagriti Rai works with The Indian Express, where she writes from the vital intersection of law, gender, and society. Working on a dedicated legal desk, she focuses on translating complex legal frameworks into relatable narratives, exploring how the judiciary and legislative shifts empower and shape the consciousness of citizens in their daily lives. Expertise Socio-Legal Specialization: Jagriti brings a critical, human-centric perspective to modern social debates. Her work focuses on how legal developments impact gender rights, marginalized communities, and individual liberties. Diverse Editorial Background: With over 4 years of experience in digital and mainstream media, she has developed a versatile reporting style. Her previous tenures at high-traffic platforms like The Lallantop and Dainik Bhaskar provided her with deep insights into the information needs of a diverse Indian audience. Academic Foundations: Post-Graduate in Journalism from the Indian Institute of Mass Communication (IIMC), India’s premier media training institute. Master of Arts in Ancient History from Banaras Hindu University (BHU), providing her with the historical and cultural context necessary to analyze long-standing social structures and legal evolutions. ... Read More