A Delhi District Consumer Commission held a private insurance company liable for deficiency in service for rejecting a 76-year-old senior citizen’s medical claim over a clerical error regarding kidney disease, and ordered it to reimburse Rs 3.87 lakh.A bench president Divya Jyoti Jaipuriar and member Rashmi Bansal, also ordered Rs 50,000 compensation for subjecting a senior citizen to harassment, and Rs 35,000 towards litigation expenses“The opposite party failed to process and decide the complainant’s claim in a fair, reasonable, and diligent manner and thereby committed a deficiency in service. We also find that the denial of cashless authorisation had a direct financial consequence for the complainant,” the commission said on September 24.Also Read | Insurer rejects heart treatment claim over ‘no original records’, family wins Rs 13.8 lakhThe commission noted that the very purpose of availing health insurance with a cashless facility is to enable the insured, subject to the terms of the policy and admissibility of the claim, to obtain hospital treatment without having to arrange the entire hospital expenditure immediately from personal resources.Senior citizen denied insurance claimA 76-year-old senior citizen purchased two “platinum” health insurance policies from a private insurance company in June 2023, totaling a sum insured of Rs 35 lakh. While buying the policies, she disclosed her pre-existing medical conditions (diabetes, hypertension, and high cholesterol) and passed the insurance company’s pre-medical examination without any record of heart or kidney issues.In December 2023, she was admitted to Max Super Speciality Hospital, Shalimar Bagh. According to the complainant, during her initial emergency admission, a doctor mistakenly noted “Chronic Kidney Disease” (CKD) in her files.According to the woman, this clerical mistake was corrected before her discharge via an official addendum on December 30, 2023, along with normal kidney test results and a clarification letter from her treating doctor confirming she had no prior history of kidney or heart disease.Story continues below this adThe complainant alleged that the insurance company denied cashless treatment at the hospital, forcing her to pay the total bill of Rs 3.87 lakh out of pocket.When she applied for reimbursement, the insurer repeatedly requested additional documents and insisted on a separate affidavit from the emergency doctor, despite being provided with all corrected medical records and clarifications. On April 25, 2024, the insurer officially rejected her claim on the ground of non-submission of required documents.Policyholder failed to supply mandatory documents: InsurerThe insurance company submitted that the policyholder failed to supply mandatory medical documents despite repeated reminders. It argued that a formal affidavit from the emergency resident doctor was necessary to resolve the discrepancy regarding the initial recording of chronic kidney disease in the hospital notes, and that the claim could not be processed without it.The company maintained that, as an insurer, it had the legal right to seek comprehensive medical records, clarifications, and past treatment details (including heart and kidney histories) to verify the legitimacy and etiology of the claim before approving reimbursement.Story continues below this adKidney disease mention was clerical error: OrderThe commission noted that the mention of chronic kidney disease was a clerical error made by the emergency resident doctor, which was corrected via an official addendum on December 30, 2023, before the patient was discharged. The commission emphasised that this discrepancy was not invented after the claim was filed, but was corrected in real time during hospitalisation.The commission observed that the insurance company’s insistence on a separate affidavit from the emergency doctor was unnecessary and unreasonable. The hospital had already issued an official letterhead clarification, the treating doctor confirmed normal kidney function tests, and the emergency doctor had already corrected the record on file.While acknowledging that insurers have the right to request documents to verify claims, the commission held, “However, such right cannot be exercised in a manner whereby the insured is repeatedly called upon to furnish documents which have already been supplied or documents which, in the circumstances, are not reasonably capable of being obtained.”The commission highlighted that the insured had disclosed her pre-existing conditions and passed the insurer’s pre-medical examination before policy issuance, with no record of heart or kidney disease.Story continues below this adTakeawayThe judgment underscored that insurers cannot reject legitimate medical claims by repeatedly seeking documents already furnished, particularly when discrepancies are promptly corrected. It reinforces the need for fair, reasonable, and diligent claim processing while protecting senior citizens from avoidable financial hardship.Consumers facing similar grievances may contact the consumer helpline in their respective states (Delhi helpline: 011-23379146) or dial the National Consumer Helpline at 1915 for assistance.