State Consumer Disputes Redressal Commission
M/S. Bajaj Allianz General Insurance ... vs Smt. Menka on 30 April, 2026
FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026
IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL
COMMISSION
Date of Institution: 05.04.2024
Date of hearing: 16.12.2025
Date of Decision: 30.04.2026
FIRST APPEAL 251/2024
IN THE MATTER OF
BAJAJ ALLIANZ GENERAL INSURANCE
COMPANY LTD.,
12TH FLOOR, DR,GOPALDASS BHAWAN,
28, BARAKHABMA ROAD,
CONNAUGHT PLACENEW DELHI-110001
(Through: Mr. Amit Kumar Maihan, Advocate)
.... Appellant
VERSUS
MRS.MENKA,
83,HARI VIHAR,KAKROLA,
NEW DELHI.
(Through: Mr. Shripal, Advocate)
...Respondent
ALLOWED PAGE 1 OF 13
FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)
HON'BLE MS. BIMLA KUMARI, MEMBER (FEMALE)
Present: Ms. Binny Sethi, Counsel for the appellant
Mr. Shripal, Counsel for the respondent
PER :HON'BLE JUSTICE SANGITA DHINGRA SEHGAL,
PRESIDENT
JUDGMENT
1. The facts of the case as per the District Commission record are as under:
"1. The present complaint has been filed under Section 12 and 35 of the Consumer Protection Act, 1986 (in short CP Act) against Opposite Party (in short OP) alleging deficiency of services.
2. Briefly stated the facts of the case are that the complainant had taken a on line health insurance policy bearing no. OG-23-1101-8441-00000078 from opposite party. The said policy was valid from 20.04.2022 to 19.04.2023. for the sum insured of Rs. 10,00,000/- (Rupees Ten Lacs Only).
3. That the complainant got admitted in the New Life Multispecialty Hospital on 31.05.2022 and remained hospitalized till 04.06.2022. The said hospital generated the final bills of Rs.45,308/- (Rupees Forty Five Thousand Three Hundred Eight) which was paid by complainant.
4. Complainant claimed the aforesaid bill amount from the opposite party, but the same was rejected by the opposite party vide repudiation letter dated 24.08.2022 with the reasons stated as under:
Verification of claim documents reveal aforesaid claimant was hospitalized for investigation and treatment of Acute gastroenteritis and is claiming for expenses of INR 45,308/-(Rupees Forty Five Thousand Three Hundred Eight). As per received documents we have noticed certain discrepancies ALLOWED PAGE 2 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026 and lapses in your hospitalization, which are as follows.
(1) Patient presented with complaints and got admitted to hospital but first consultation detail not available, Also no any post discharge follow up treatment taken.
(2) All indoor case paper are written in single handwriting.
(3) Insured denied to provide any google timeline of his mobile.
4) Multiple IV antibiotics used without any OPD treatment.
(5) Hospital registration paper not shared by concern authority (6) In-patient pharmacy purchase bill is not supported by purchase invoice from either hospital or patient (7) Patients pathology cell counter record not shared by the hospital authority.
(8) Patient father denied to share payment clearing record.
(9) Complaints and treatment does not follow standard protocols for patient care, Also the hospital authority did not provide any contact detail of treating doctor. Hence, we regret to inform that your claim stands repudiated in view of misrepresentation of facts with non-
cooperation, Section E) General Terms and Clauses-Standard must be fulfilled by the insured person for the company to make any payment for claim(s) arising under the policy.
5. It is further alleged that the complaint is being filed within the period of limitation. The cause of action arose when the claim of the complainant rejected by opposite party on dated 24.08.2022.
6. It is prayed that OP be directed to pay a sum of Rs.45,308/- (Rupees Forty Five Thousand Three Hundred Eight) to the complainant with pendentelite and future interest @ 18% p.a. from the date of ALLOWED PAGE 3 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026 repudiation letter dated 24.08.2022 till realization and cost of litigation be also awarded
7. Notice of the complaint was issued to OP, OP was duly served on 07.12.2022. However OP did not filed written statement within statutory period in view of Section 38(3)(a) of the Consumer Protection Act, 2019 the same was not taken on record and as such the defence of OP was struck off vide order dated 14.02.2023.
8. In this regard the Hon'ble Supreme Court has held in the case titled New India Assurance Company Ltd. Vs. Hilli Multipurpose Cold storage Pvt. Ltd. reported in 2020 (5) SCC 757 as under:
"Sub Section (2)(a) of Section 13 of the Consumer Protection Act provides for the opposite party to give his response 'within a period of 30 days or such extended period not exceeding 15 days as may be granted by the District Forum'. The intention of the legislature seems to be very clear that the opposite party would get the time of 30 days, and in addition another 15 days at the discretion under the Act".
9. Complainant filed her evidence by affidavit reiterating therein the averments made in the complaint.
Complainant relied upon the treatment record, the bills issued by New Life Multispecialty Hospital, the repudiation letter.
10. We have heard the AR of complainant and counsel for OP and perused the record."
2. The District Commission after taking into consideration the material available on record passed the order dated 08.01.2024 whereby it held as under:
"11. In view of the unrebutted testimony of complainant and the documents filed and replied upon, we are of the view that complainant has succeeded in proving that OP was guilty of deficiency of services in repudiating the claim of complainant. It is to be noted ALLOWED PAGE 4 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026 complainant was hospitalized during the tenure of the coverage of policy in the panel hospital of OP. We accordingly hold OP/Bajaj Allianz General Insurance Company guilty of deficiency of services and direct OP to pay Rs.45,308/- (Rupees Forty Five Thousand Three Hundred Eight) to the complainant with interest @ 9% per annum from date of filing of claim, within four weeks of date of receipt of order, failing which OP will be liable to pay interest @ 12% per annum till realization. We also direct OP to pay compensation of Rs.25,000/ (Rupees Twenty Five Thousand only) for mental agony and harassment. A copy of this order be sent/provided to all the parties free of cost. The order be uploaded on the website of this Commission.
File be consigned to record room along with a copy of the order."
3. Aggrieved by the aforesaid order of the District Commission, the Appellant has preferred the present Appeal contending that the patient got directly admitted in the hospital without any prior OPD treatment and also did not take post discharge follow up / treatment. It is further submitted that the medical documents are in single scripted handwriting written in one stretch and as per the industry records, the said hospital is involved in a nexus of fraudulent activities. Secondly, it is submitted that the patient / Insured denied to provide any google timeline of his mobile and multiple IV antibiotics were used without any OPD treatment. It is further submitted that Hospital registration papers were not shared by concerned authority. Thirdly, it is submitted that In-patient pharmacy purchase bill is not supported by purchase invoice from either hospital or patient and patient's pathology cell counter record was not shared by the hospital authority. Fourthly, it is submitted that Pateint's father denied to share payment clearing record nor does the treatment follow standard protocols for patient care. Moreover, contacts details of the treating doctor were not provided by ALLOWED PAGE 5 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026 the hospital. Lastly, it is submitted that the District Commission ought not to have ignored the fact that multiple unrelated claims of similar nature were lodged by the respondent against the appellant with 3-4 common problems in 12 different cases. Pressing the aforesaid submissions, the Appellant has prayed that the Impugned Order be set aside.
4. The Respondent has filed the Reply to the Appeal and has stated therein the claim was rightly decided by the District Commission. Secondly, it is submitted that the present appeal is absolutely frivolous and concocted and is filed with the sole motive to waste the precious judicial time of this Commission. Lastly, it is submitted that the District Commission duly considered the material available on record and passed the Impugned Order in all fairness, thus the Impugned Order warrants no interference. Pressing the aforesaid submissions, the Respondent has submitted that the present appeal be dismissed with heavy costs.
5. Parties have filed their brief Written Arguments and the same have been given due consideration
6. We have perused the material available on record.
7. The only question that falls for our consideration is whether the District Commission erred in holding the Appellant liable for deficiency in service.
8. The facts of the case reflect that the Respondent Insured had taken an online health insurance policy bearing no. OG-23-1101-8441-00000078 from the Appellant which was valid from 20.04.2022 to 19.04.2023, for a sum insured of Rs. 10,00,000/-. The Respondent's daughter/patient-Tannu Shree got admitted in New Life Multispecialty Hospital for treatment of acute gastroenteritis on 31.05.2022 and remained hospitalized till 04.06.2022. The said hospital generated the final bills of Rs.45,308/- which was paid by the Respondent. The Respondent thereafter claimed the aforesaid bill amount from the Appellant which was rejected by the ALLOWED PAGE 6 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026 Appellant vide repudiation letter dated 24.08.2022, with the reasons stated as under:
"Verification of claim documents reveal aforesaid claimant was hospitalized for investigation and treatment of Acute gastroenteritis and is claiming for expenses of INR 45,308/-(Rupees Forty Five Thousand Three Hundred Eight). As per received documents we have noticed certain discrepancies and lapses in your hospitalization, which are as follows.
(1) Patient presented with complaints and got admitted to hospital but first consultation detail not available, Also no any post discharge follow up treatment taken. (2) All indoor case paper are written in single handwriting. (3) Insured denied to provide any google timeline of his mobile. 4) Multiple IV antibiotics used without any OPD treatment. (5) Hospital registration paper not shared by concern authority (6) In-patient pharmacy purchase bill is not supported by purchase invoice from either hospital or patient (7) Patients pathology cell counter record not shared by the hospital authority. (8) Patient father denied to share payment clearing record. (9) Complaints and treatment does not follow standard protocols for patient care, Also the hospital authority did not provide any contact detail of treating doctor. Hence, we regret to inform that your claim stands repudiated in view of misrepresentation of facts with non-cooperation, Section E) General Terms and Clauses-Standard must be fulfilled by the insured person for the company to make any payment for claim(s) arising under the policy."
9. On the other hand, it is the primary contention of the Appellant that multiple discrepancies were found in the hospital records and therefore the claim was rightly repudiated on the grounds of misrepresentation, non-cooperation and Condition Precedent to Admission of Liability clause.
10. In order to resolve the aforesaid controversy, we deem it appropriate to refer Condition-IV(i) and Condition 10 (Condition Precedent) of the standard terms and conditions of the Policy, reproduced hereunder as:
"(i) Fraud-
ALLOWED PAGE 7 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026
i) If any claim made by the insured benefits, is in any respect fraudulent or in any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the Insured beneficiary or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited.
ii. Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient (s) policy holder (s) who has made that particular claim, who shall be jointly and severally liable for such repayment to the insurer.
iii. For the purpose of this clause, the expression fraud means any of the following acts committed by the insured beneficiary or by his agent or the hospital/ doctor/any other party acting on behalf of the Insured beneficiary, with intent to deceive the insure or to induce the insurer to issue an insurance policy"
"10. Condition precedent to Admission of liability: The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payments for claims arising under the policy"
11. A perusal of the aforesaid clause IV(i) makes it clear that the Insurer shall repudiate the claim and shall be entitled forfeit the premium paid, if it is found that the Insured beneficiary or anyone acting on his/her behalf has resorted to fraudulent means or misrepresentation to obtain any benefit under the said policy. A further perusal of the aforesaid clause 10 makes it clear that Condition Precedent means a policy term or condition upon which the Insurer's liability under the policy is conditional. The Insurer shall not be liable to make any payments against the claim arising under the policy if the Insured fails to fulfil the terms and conditions of the policy availed.
12. We further deem it appropriate to refer to the report of the Investigator-
Clever Vision (Annexed at pg-233 alongwith the Appeal), reproduced hereunder as:
ALLOWED PAGE 8 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026
"Hospital and Insured Verification: Observation at hospital and insured:
Patient named Miss Tannu Shree was admitted in New life Multispeciality Hospital Delhi, on 31/05/2022 and discharged on 04/06/2022 with final diagnosis AGE under the supervision of Dr. AKSHITA ANGADI
2. Investigator visited the hospital and collected the ICP of the case, final bill duplicate, lab register, IPD register.
3. As per ICP patient admitted on 31/05/22 with the complained of pain abdomen, loose stool and gen malaise and diagnosed as a case of AGE and after treatment discharged on 04/06/22
4. Treating dr justified the treatment
5. We tried to traced contact number of treating doctor but did not found Visit to the insured:
1. Investigator visited the insured's work place and met with pt father, he provided Aadhar card as ID proof and filled the questionnaire for pt. on 23/06/2022 in which he mentioned the details of pt illness.
2. He mentioned that he had c/o AGE with pain abdomen with loose stools and nausea and consulted in this hospital with Dr. Akshita Angadi and dr advised for admission on 31/05/22 and diagnosed as a case of AGE and discharged on 04/06/22
3. He denied to provide any Google timeline.
4. Patient father denied to share payment clearing record Discrepancies
1. Hospital did not shared purchasing invoices
2. Hospital registration papers not shared
3. Patient father Mr sripal is a nexus person who came in many cases with patients while patient verification
4. He used abused language in one case when we visited patient for statement.
5. Cell counter record not shared by the hospital
6. Payment clearing record not shared by the insured Conclusion Query needs to be raised :-
Purchasing invoices Cell counter record slips Investigation findings mentioned above as per the available facts and documents. Final decision to be taken by Insurance Company as per policy Terms and Conditions."
ALLOWED PAGE 9 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026
13. A perusal of the aforesaid investigation report makes it clear that the Hospital did not share any purchasing invoices and registration papers and the Investigation Sheet records a categorical finding to the effect that the Patient's father 'Mr. Sripal' is a nexus person who came in many cases alongwith the patients during patient verification and used abusive language when the Investigator visited the patient for statement. The Investigation sheet further reflects that when the Investigator visited the insured's workplace and met with the patient's father, the patient's father denied to provide any Google timeline and also denied to share the payment clearing record. Furthermore, it was observed that the Cell counter record and Payment clearing record was not shared by the hospital or by the insured. A further perusal of the Investigation Report makes it clear that the Investigator tried to trace the contact number of the treating doctor but the treating doctor could not be found.
14. Furthermore, it is abysmally surprising to note here that a cursory glance of the medical record makes it clear that all the general health indicators of the patient are within the reference range, and almost no health parameter of the Respondent-patient is out of the bio-reference range to indicate any ailment, yet the patient was hospitalized for 5 days. Again, the reply of the Respondent is completely silent on the aforesaid points.
15. At this juncture, it is pertinent to remark that the Hon'ble Supreme Court and the Hon'ble National Commission have time and again held that it is an established position of law that the surveyor report is an important piece of evidence. The Hon'ble National Commission in First Appeal No. 1275 of 2014 titled M/S. Bhupinder Tyres Works vs New India Assurance Company Ltd. has held that it is a well-established legal position that survey reports should be given due consideration unless they exhibit non-
consideration of material evidence or misrepresentation of facts, relevant extract reproduced hereunder as:
ALLOWED PAGE 10 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026
"It is an established legal position that survey reports need due consideration, unless the report reveals non-consideration of material evidence or misrepresentation of facts, which is not the case."
16. Here, we deem it appropriate to refer to the case of National Insurance Co.
Ltd. vs. Noli Ram and Sons, 2017 (4) CPR 388 (NC), the Hon'ble National Commission has held that surveyor report cannot be disbelieved and cannot be rejected without any forceful evidence on the part of the complainant.
17. Similarly, in the case of Ashish Kumar Jaiswal vs. ICICI Lombard General Insurance Company Ltd. and Ors., 2017 (3) CPR 71 (NC), the Hon'ble National Commission has held that the surveyor's report is only reliable document which is to be considered for settling the insurance claim, the petitioner has failed to put forward any cogent reasons to dispute surveyor's report and there is no reason to reject it.
18. Furthermore, in the case of Pradeep Sharma vs. Bajaj Allianz General Insurance Co. and Anr., 2017 (1) CPR 259 (NC), the Hon'ble National Commission has held that the assessment made by surveyor must be given due weightage. Similarly, in the case of Devender Malhotra vs. United India Insurance Co. Ltd. & Anr., 2016 (3) CPR 461 (NC), the Hon'ble National Commission has held that the report made by the surveyor cannot be disbelieved unless there are cogent and convincing reasons to do so; report of the surveyor has to be given effect to unless there are contrary reasons to disregard the same.
19. The principle as laid down in the above-mentioned cases are fully applicable to the case in hand. As per the settled law discussed above, the surveyor report is an important piece of document and it cannot be brushed aside unless and until there is some cogent and believable evidence against it. Here, it is pertinent to note that the Respondent has merely submitted ALLOWED PAGE 11 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026 that the entire Appeal is an abuse of the process of law and is filed on false and frivolous grounds. However, the Respondent has not submitted any cogent and reliable evidence that on what basis, the Investigator report was not properly assessed. Thus, we are of the definite opinion that the assessment made by the Investigator is genuine and the Investigation report cannot be brushed aside unless and until there is some cogent and believable evidence against it. In fact, the entire Reply of the Respondent is merely a repetition of the same set of words, bereft of any material particulars or cogent explanation/evidence placed on record to rebut the contentions raised by the Appellant.
20. In light of the above discussion, it is clear that the District Commission ought to have appreciated that the Investigator had categorically remarked that the claim be repudiated since the patient's father was found to be involved in a nexus indulging in unfair trade practices, refused to cooperate with the Investigator and used abusive language and the hospital denied to share the cell counter record, purchasing invoices, payment record, hospital registration papers and treating doctor could not be found, thus proving that there was a clear violation of the Condition IV (i) and Condition Precedent to Admission of Liability of the standard terms and conditions of the policy.
21. Therefore, we opine that the Appellant rightly repudiated the claim of the Respondent after getting the necessary investigation done and no deficiency of service can be carved out on the part of the Appellant.
22. Consequently, the present Appeal is allowed and the order dated 08.01.2024 passed by the District Consumer Disputes Redressal Commission-VI, M-Block, Vikas Bhawan, I.P.Estate, New Delhi-110002 is set aside.
23. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment
24. FDR, if any, be released in favour of the Appellant.
ALLOWED PAGE 12 OF 13 FA 251/2024 BAJAJ ALLIANZ GIC CO. LTD. VS MRS. MENKA D.O.D.: 30.04.2026
25. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
26. File be consigned to record room along with a copy of this Judgment.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (BIMLA KUMARI) MEMBER (FEMALE) Pronounced On:
30.04.2026 L.R.-G.P.K ALLOWED PAGE 13 OF 13