Son Wins Rs 6 Lakh Claim Against HDFC ERGO Over Father's Health Insurance Denial
Health insurance company denies claim over father’s alleged alcohol history; son fights back and wins Rs 6 lakh
Image: The Economic Times
A software engineer from Andhra Pradesh successfully challenged HDFC ERGO's denial of a health insurance claim for his father, who suffered severe injuries in an attack. The District Consumer Disputes Redressal Commission ordered the insurer to pay Rs 6 lakh, citing unjustified claim rejection despite clarifications about the father's medical history.
- 01The complainant incurred over Rs 10 lakh in medical expenses for his father after a violent attack.
- 02HDFC ERGO denied the claim based on a misinterpreted reference to 'Alcohol Withdrawal Psychosis' in the hospital discharge summary.
- 03The hospital clarified that the father's symptoms were due to chronic kidney disease, not alcohol use.
- 04The Consumer Commission ruled the insurer's actions as arbitrary and a deficiency in service.
- 05The hospital was also held accountable for the initial misleading diagnosis.
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A software engineer from Andhra Pradesh faced a significant challenge when HDFC ERGO denied his health insurance claim for his father, who suffered serious injuries during a violent attack. The insurer's rejection was based on a reference to 'Alcohol Withdrawal Psychosis' in the discharge summary from Continental Hospitals, which was later clarified as a provisional diagnosis due to the father's actual medical condition, chronic kidney disease. Despite the hospital's revisions and confirmations that the father had no history of alcohol consumption, HDFC ERGO maintained its stance, leading to a legal battle. The District Consumer Disputes Redressal Commission ultimately ruled in favor of the complainant, ordering HDFC ERGO to pay Rs 6 lakh plus interest and holding the hospital accountable for its initial diagnosis. This case underscores the importance of accurate medical documentation and the need for insurers to substantiate claims of misrepresentation.
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The ruling reinforces consumer rights in health insurance claims and emphasizes the need for insurers to provide valid reasons for claim denials.
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