Across Gujarat, claims have been contested over undisclosed illnesses, hospitalisation, paperwork discrepancies, blacklisted hospitals and whether procedures were medical or cosmetic
When his family filed a Rs 2 lakh claim, the insurer argued that if he could appear for an exam, he did not require hospitalisation.
Sometimes they also question the number of days of admission, saying the stay was excessive,” said a doctor at a Vadodara hospital. It becomes strenuous for patients and their families,” the doctor said. Vadodara consumer lawyer Hardik Shah says the problem becomes particularly difficult when treatment cannot wait. Many of these issues come up only when the claim is processed,” Shah said. In Ahmedabad, a pneumonia claim for an eight-year-old girl with Rett Syndrome was eventually allowed after doctors said the two were unrelated. “The insurer’s perspective is that suppression by the insured is itself a ground for repudiation,” Raval said.
His doctor allowed him to leave temporarily to take an exam. The consumer forum disagreed and ordered payment. “An oft-repeated reason given by insurers is that there was no need for the patient to be admitted. He recalled a senior citizen admitted after a heart attack whose cashless treatment was held up by repeated queries. “Sometimes cashless approval is withdrawn or questioned at discharge, with fresh documents demanded and minor technical points raised. “In an emergency, families are concerned with getting the patient admitted. They are not in a position to first check whether the hospital is blacklisted, whether it has a minimum number of beds or whether some other technical condition may later be raised. Medical history is another major source of litigation. Two recent cases asked the same question: can an undisclosed condition justify rejecting a claim for unrelated treatment? In Surat, the insurer was similarly ordered to pay a cataract claim it had rejected over the non-disclosure of Parkinson’s disease after failing to establish a nexus between the two conditions. “However, courts, including the Supreme Court in cases before it, have held that when the suppression has no nexus with the treatment claimed, the claim can become payable. Insurers say the question of non-disclosure is more nuanced.
For a 69-year-old Surat man, it took 12 years. His battle began after he suffered an acute stroke in Manchester, UK, in 2009. His insurer initially approved cashless treatment there but later refused to pay, citing 15 years of undisclosed diabetes. He paid the 4,283-pound bill (about Rs 3.5 lakh) himself, and went to the Surat district consumer court and won. In 2021, the commission dismissed the insurer’s appeal as lacking merit, calling diabetes and hypertension lifestyle diseases. Since 1989, Gujarat has recorded 3.3 lakh consumer cases, including 1.4 lakh insurance-related disputes across categories. In one Vadodara case, an insurer rejected a Rs 58,953 claim for enteric fever treatment after an investigator used the patient’s phone GPS history to argue that he was not in hospital on the dates claimed. The consumer commission rejected the contention, observing that the phone could have been carried elsewhere by someone else, and ordered the insurer to pay the claim with 8% interest and costs.
The insurer appealed before the state consumer commission and lost, then took the case to the national consumer commission. Buying a health insurance policy can take half an hour. Fighting a rejected claim can become a long ordeal. Across Gujarat, claims have been contested over undisclosed illnesses, hospitalisation, paperwork discrepancies, blacklisted hospitals and whether procedures were medical or cosmetic. The insurer also alleged discrepancies in hospital records submitted with the claim.
