In a landmark ruling, the District Consumer Disputes Redressal Commission in Mohali has directed HDFC ERGO Health Insurance Ltd (formerly Apollo Munich) to pay ₹2.01 lakh with 6% annual interest and an additional ₹30,000 as compensation for wrongfully denying a genuine medical claim.
Case Background: Policyholder Denied Reimbursement Despite Valid Coverage
The complainant, Kuldeep Singh Sandhu, a resident of Kharar, had purchased a group mediclaim policy through Canara Bank for himself and his wife, with a sum insured of ₹5 lakh. In March 2020, Sandhu was hospitalized at Sri Guru Harkrishan Sahib Eye Hospital, Sohana, with symptoms including vomiting, vertigo, and slurred speech.
However, his request for cashless treatment was denied by HDFC ERGO, citing a pre-existing coronary artery disease (CAD)—a claim the insurer failed to substantiate with medical evidence. The policy was abruptly terminated the next day.
Consumer Court Slams Insurer for Deficiency in Service
Despite Sandhu submitting medical certificates from two doctors confirming no history of CAD, the insurer refused to reimburse the ₹2.01 lakh he paid out-of-pocket for two hospitalizations. The commission ruled that the insurer had engaged in unfair trade practices and failed to justify the rejection.
“Insurance companies entice customers at the time of policy sale but try to escape responsibility when it comes to settling genuine claims,” the commission observed.
Verdict and Penalty
- ₹2.01 lakh to be paid with 6% interest from March 23, 2020
- ₹30,000 awarded for mental harassment and litigation costs
- Interest will rise to 9% if payment is delayed beyond 30 days
- Insurer permitted to seek any pending documentation within 30 days
This ruling reinforces the accountability of insurers and the rights of policyholders under India’s consumer protection laws.
