The Delhi State Consumer Disputes Redressal Commission ruled in favour of Bajaj Allianz General Insurance, setting aside an earlier district commission order that had directed the insurer to pay Rs 41,530 to the policyholder along with interest and compensation. The case involved Pooja Kumari, who purchased an online health insurance policy valid from July 2021 to July 2022 with a sum insured of Rs 3 lakh. She was admitted to Mahavir Multispeciality Hospital in April 2022 for treatment of Macrocytic Anaemia and remained hospitalized from April 1 to April 5, incurring a bill of Rs 41,530.

Bajaj Allianz rejected the claim in July 2022 after its investigation agency identified a series of inconsistencies in the medical records. The most significant finding was a contradiction between the discharge summary and treatment records: the discharge summary indicated the patient was discharged at 12:42 PM on April 5, yet inpatient case papers showed that vital signs were recorded and an injection was administered at 1:00 PM the same day, approximately 20 minutes after the alleged discharge.

The investigation uncovered nine additional discrepancies beyond this primary finding. The pathologist named on the lab reports, Dr K.D. Gandhi, confirmed in writing that the reports submitted under the patient's name were not verified by him. Symptoms recorded in inpatient case papers differed from what the patient herself reported during investigation, and post-discharge medications listed in nursing records contradicted the patient's statement. Additionally, the hospital was not registered under DGHS for inpatient treatment at the time of the claim.

The commission noted that the district commission had committed a "glaring error" in concluding that the patient had been treated under Dr Gandhi's supervision "when Dr K.D. Gandhi has himself denied the same." Applying the fraud clause in the policy's standard terms and conditions, which allows forfeiture of benefits if forged or fabricated claim documents are submitted, the commission held that the insurer had valid grounds to repudiate the claim. The state commission concluded that the claim was rightly rejected in accordance with the policy terms and no deficiency of service could be attributed to the insurer.