• Medi claim rejected

My son had a apendix operation in Dec 2022 .The medi-claim company rejected the health claim with the reason that there are multiple discrepancies in the claimed expenses/submitted documents .

Each and every Document/ Bill was provided by us given by the hospital.The actual scanned copies of each bill was given as requested in the email chain communication with Medical insurance company.We raised the matter with the ombudus man of the company seeking the details of the discrepancies in the documents so that we can clear any mis-information and did not get any further explanation in response:

Below is the reason in the denial letter:

On Perusal of claim documents ,we found that Insured Parth
Ahuja admitted at Pushpanjali Medical Centre From
09/12/2022 to 12/12/2022 for management of Acute
appendicitis .After internal claim verification we have noted
multiple discrepancies in the claimed expenses/submitted
documents, hence we regret to inform you that your your claim
stands repudiated as per policy terms and conditions

The denial clause :

Please Refer Policy General Terms & Conditions_ Clause No:
10.9. Fraud If any claim made by the insured person, is in any
respect fraudulent, or if any false statement, or declaration is
made or used in support thereof, or if any fraudulent means or
devices are used by the insured person or anyone acting on
his/her behalf to obtain any benefit under this policy, all
benefits under this policy shall be forfeited. Any amount
already paid against claims which are found fraudulent later
under this policy shall be repaid by all person(s) named in the
policy schedule, who shall be jointly and severally liable for
such repayment. For the purpose of this clause, the expression
"fraud" means any of the following acts committed by the
Insured Person or by his agent, with intent to deceive the
insurer or to induce the insurer to issue an insurance Policy: -
a) The suggestion, as a fact of that which is not true and
which the Insured Person does not believe to be true; b) the
active concealment of a fact by the Insured Person having
knowledge or belief of the fact; c) any other act fitted to
deceive; and d) any such act or omission as the law specially
declares to be fraudulent The company shall not repudiate the
policy on the ground of fraud, if the insured person /
beneficiary can prove that the misstatement was true to the
best of his knowledge and there was no deliberate intention to
suppress the fact or that such mis-statement of or suppression
of material fact are within the knowledge of the insurer. Onus
of disproving is upon the policyholder, if alive, or beneficiaries.

Kindly advice on next steps for legal remedies.

Sachin kl Ahuja
Asked 13 days ago in Consumer Law

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8 Answers

Health insurance companies are habitual in rejecting claims these days. It's like each one of them has decided not to settle the claim of the insured. In my practice, I've dealt with more than 30 cases (including 4 of my own family) regarding the repudiation of health claims. Luckily, all went in my favour. In every case, the consumer commission has held that these companies had made the mood of not giving claims to the insureds/beneficiaries. 




I suggest you to move a comlaint in the consumer commission and affix all the necessary documents in support thereof. If you can share the policy document; it would be great for further suggestions. 

Nikhil Gupta
Advocate, Yamunanagar
128 Answers
1 Consultation

4.0 on 5.0

If your son's health insurance claim was denied due to multiple discrepancies in the claimed expenses/submitted documents, you may have the right to appeal the decision. The denial letter you received should provide information on how to appeal the decision. It is important to review the denial letter carefully to understand the reason for the denial and to make sure you are following the correct procedure for appealing the decision.

You may also want to consider filing a complaint with your state's insurance department. The National Association of Insurance Commissioners (NAIC) provides a list of state insurance departments on their website. You can contact the insurance department in your state to file a complaint and to get more information about the appeals process.

You may also want to consider consulting with a lawyer who specializes in insurance law. 

Mohammed Mujeeb
Advocate, Hyderabad
19292 Answers
32 Consultations

4.7 on 5.0

You better consult an experienced lawyer in the local, discuss the subject matter at length and on his or her advice you may first issue a legal notice to the insurance company blaming them for deficiency in service and for causing mental agony besides cheating the customers after selling the policy by repudiating the insurance claim on some flimsy or non maintainable reasons.

Subsequent to legal notice, if you don't get any relief you may drag the insurance company to consumer forum seeking relief and remedy.

It is common among the insurance company to reject the claim without proper reason just to avoid claim settlement.

This is an illegal act but you can approach consumer forum for relief.

T Kalaiselvan
Advocate, Vellore
80652 Answers
1740 Consultations

5.0 on 5.0

You can send them a notice and file a consumer complaint in consumer court 

Prashant Nayak
Advocate, Mumbai
29082 Answers
113 Consultations

4.1 on 5.0

File complaint against insurance company before consumer forum and seek orders to direct insurance company to pay amount claimed 


2) also seek litigation costs and compensation for mental torture undergone by you 

Ajay Sethi
Advocate, Mumbai
90487 Answers
6636 Consultations

5.0 on 5.0

You should now approach Insurance Ombudsman ( Noida)

If insurance Ombudsman also rejected the claim ( which is very less chance if you take the help of lawyer)...then you should approach consumer court ( Ghaziabad)



Ravi Panwar
Advocate, New Delhi
66 Answers

Not rated

- You can enquire from the said Insurance Company for the actual reasons for the rejection and try to remove those discrepancies. 

- If even the claim rejected , then you can send a legal notice to getting the same , and if no response, then file a compliant before the consumer forum against that Insurance company for claiming the claim and the compensation for harassment . 

Mohammed Shahzad
Advocate, Delhi
10878 Answers
136 Consultations

5.0 on 5.0

If you are dissatisfied with the decision of the insurance company, you can explore the following legal remedies:


Appeal: You can appeal the decision of the insurance company within a stipulated time frame. Check the terms and conditions of your policy for details on the appeal process.


Ombudsman: You can approach the insurance ombudsman, who is an independent authority appointed by the government to resolve disputes between insurance companies and their policyholders. The ombudsman can help resolve disputes through mediation or arbitration.


Consumer forum: You can approach the consumer forum if the insurance company is not responsive or if you are not satisfied with the resolution provided by the ombudsman. The consumer forum can help resolve disputes through a legal process.


Legal action: If all else fails, you can take legal action against the insurance company in a court of law. It is advisable to consult a lawyer before taking this step.


Before taking any legal action, ensure that you have all the necessary documents and evidence to support your claim. Also, make sure that you have followed the appeal process and exhausted all other options before approaching a consumer forum or taking legal action.




Anik Miu
Advocate, Bangalore
6256 Answers
68 Consultations

4.9 on 5.0

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