The District Consumer Disputes Redressal Commission in Mohali has ruled in favor of a policyholder, Kuldeep Singh Sandhu, who was wrongfully denied a mediclaim by HDFC ERGO Health Insurance Ltd. Sandhu had purchased a group mediclaim policy through Canara Bank, which covered both him and his wife for a sum insured of Rs 5 lakh.
In March 2020, Sandhu was admitted to the hospital with symptoms such as vomiting, vertigo, and facial numbness. However, his request for cashless treatment was denied by HDFC ERGO, citing pre-existing coronary artery disease (CAD). The policy was subsequently terminated. Despite providing medical certificates from cardiologists confirming no history of CAD, the insurance company refused to reimburse the hospital expenses.
As a result, Sandhu had to pay Rs 2,01,006 out of pocket for his hospital expenses. The commission noted that the insurer failed to provide credible proof of any pre-existing illness and accused it of adopting unfair trade practices. The commission observed that insurance companies often try to escape responsibility when it comes to settling genuine claims.
The commission has directed HDFC ERGO to pay the full amount of Rs 2.01 lakh along with 6% annual interest from the date of discharge. The company has also been directed to pay Rs 30,000 as compensation to the policyholder. If the payment is not made, the interest will rise to 9%. The insurer has been permitted to seek any pending documentation from the complainant within 30 days. This ruling highlights the importance of insurance companies fulfilling their obligations and settling genuine claims in a fair and timely manner.