The District Consumer Disputes Redressal Commission in Mohali has ordered HDFC ERGO Health Insurance Limited to reimburse ₹2 lakh to a policyholder, Kuldeep Singh Sandhu, who was wrongly denied a mediclaim. Sandhu had purchased a group mediclaim policy from Apollo Munich through Canara Bank, which provided a cover of ₹5 lakh for both him and his wife. The policy was valid from November 2019 to November 2020. In March 2020, Sandhu was admitted to a hospital after experiencing symptoms such as vomiting, numbness, and slurred speech.
The insurer, HDFC ERGO, denied the cashless treatment request, citing pre-existing Coronary Artery Disease (CAD) as the reason. However, Sandhu contested this claim, submitting medical evidence from a cardiologist that showed he had no history of CAD. Despite this, the insurer did not approve the claim, forcing Sandhu to pay over ₹2 lakh in hospital expenses. The consumer commission noted that the insurer failed to produce any credible evidence proving that Sandhu had CAD prior to the policy’s inception.
The commission held HDFC ERGO guilty of deficiency in service and unfair trade practices, stating that insurance companies often entice customers at the time of policy sale but fail to take responsibility when it comes to settling genuine claims. The commission directed the insurer to reimburse the full hospital bill with 6% annual interest from the date of discharge, within 30 days. If the insurer fails to comply, the interest rate will increase to 9% per annum. Additionally, the commission awarded ₹30,000 as compensation for mental harassment and litigation costs.
The commission’s decision highlights the importance of insurance companies being transparent and fair in their dealings with policyholders. It also emphasizes the need for policyholders to carefully review their policies and seek medical evidence to support their claims. In this case, Sandhu’s efforts to contest the insurer’s decision and provide medical evidence ultimately led to the commission’s decision in his favor. The decision serves as a reminder to insurance companies to prioritize their customers’ needs and to take responsibility for settling genuine claims in a fair and timely manner.