If you’re experiencing this problem with this brand or any other company, submit your complaint and we may feature it on Choice4Voice.com.
Submit your complaint →Mohit Sethi alleges HDFC ERGO General Insurance denied a valid cashless claim for his father’s acute liver abscess treatment costing ₹8,91,500. Doctors confirmed it was a sudden onset, but the insurer cited “pre-existing condition.”
Complaint Summary : HDFC ERGO Denies Critical Cashless Claim for Acute Liver Abscess Treatment – Complaint by Mohit Sethi
| Details | Information |
|---|---|
| Complainant Name | Mohit Sethi |
| Not disclosed | |
| Company/Brand | HDFC ERGO General Insurance |
| Complaint Type | Health Insurance Claim Rejection |
| Product/Service | Cashless Mediclaim Facility |
| Issue Description | Cashless claim for father’s critical liver abscess treatment (₹8,91,500) denied, citing “possible pre-existing condition” despite no medical evidence. |
| Date of Incident | September 2025 |
| Order/Policy No. | Not disclosed |
| Company’s Response | Denied claim |
| Complainant Comments | Denial has put family in financial distress; seeking urgent support and legal recourse. |
Full Complaint Write-up
Mohit Sethi, a professional from Delhi, raised a serious complaint against HDFC ERGO General Insurance after the company denied a critical cashless claim for his father’s ongoing medical treatment.
His father, aged 51, has been diagnosed with Infectious Liver Abscess Disease, and doctors issued a cost estimate of ₹8,91,500 for urgent treatment. Despite having an active HDFC ERGO health insurance policy, the claim was rejected on the grounds of a “possible pre-existing condition.”
Mohit argues that the denial is baseless and unfair because:
- Liver abscess is acute in onset and not a chronic pre-existing disease.
- Multiple studies (NCBI, PubMed, Indian clinical studies) confirm liver abscess develops suddenly within 10–20 days.
- Doctors certified his father’s condition as sudden onset (not more than 10–14 days).
- No mention of this illness exists in the pre-existing disease exclusion list in the policy documents.
Due to this denial, Mohit’s family is facing severe financial and emotional distress, trying to arrange funds while continuing treatment.
He has vowed to take legal action against HDFC ERGO for unfair practices but has also sought urgent public support to save his father’s life.
Legal Remedies Available
If you face a similar insurance denial, you can take the following legal steps:
- IRDAI Complaint: File a grievance with the Insurance Regulatory and Development Authority of India (IRDAI) via igms.irda.gov.in.
- Insurance Ombudsman: Approach the Insurance Ombudsman under the Redressal of Public Grievances Rules, 1998.
- Consumer Forum Case: File a case under the Consumer Protection Act, 2019 for deficiency in service and unfair trade practice.
- Civil Court Suit: Claim damages and reimbursement for financial loss and mental harassment.
- Medical Board Certification: Obtain a written certification from doctors stating the illness is acute and not pre-existing.
Authorities Where Complaint Can Be Filed
- IRDAI (Insurance Regulator) – for regulatory complaint.
- Insurance Ombudsman Office – free, time-bound resolution.
- District Consumer Disputes Redressal Commission (DCDRC) – for claims up to ₹50 lakh.
- State Consumer Disputes Redressal Commission (SCDRC) – if claim exceeds ₹50 lakh.
- National Consumer Disputes Redressal Commission (NCDRC) – for high-value cases.
How Choice4Voice.com Can Help
At Choice4Voice.com, we specialize in amplifying genuine consumer complaints ignored by large corporations. In this case, Mohit Sethi’s father’s life-saving treatment was jeopardized due to an unfair insurance rejection.
We:
- Highlight such cases across digital platforms to ensure accountability.
- Provide legal guidance and complaint templates for IRDAI, Ombudsman, and Consumer Courts.
- Connect victims with lawyers, NGOs, and patient advocacy groups for stronger action.
Pre-Drafted Complaint Templates
✅ IRDAI Grievance Email Template
Subject: Urgent Complaint Against HDFC ERGO – Unfair Claim Rejection
Dear IRDAI Grievance Cell,
I, [Your Name], policyholder of HDFC ERGO, am filing this complaint against the insurer for rejecting my valid cashless claim for [patient name] suffering from acute liver abscess. The rejection cites “pre-existing condition” without medical basis. Doctors have certified it as sudden onset.
Request IRDAI’s urgent intervention to ensure justice and reimbursement.
Regards,
[Your Name]
Policy Number: [Insert]
✅ Consumer Forum Complaint Draft
Includes sections on:
- Complainant details
- Policy details
- Nature of illness
- Grounds of rejection
- Relief sought: reimbursement + compensation for harassment
Brand Background – HDFC ERGO General Insurance
- Joint venture of HDFC Ltd. and ERGO International AG (Munich Re Group).
- One of India’s largest private general insurers.
- Offers motor, health, travel, home, and commercial insurance.
- Has faced several consumer complaints regarding delayed or denied claims.
Official Contact (for escalation):
📧 grievance@hdfcergo.com
🌐 www.hdfcergo.com
Author
Complainant: Mohit Sethi
Fraud Analysis Professional – Genpact | Zomato | Harvard ’24
Q&A Section
1. Why did HDFC ERGO reject Mohit Sethi’s father’s cashless claim?
The insurer cited “possibility of pre-existing condition,” but doctors confirmed the illness was acute and not pre-existing.
2. What is liver abscess disease?
A liver abscess is a pus-filled cavity caused by infection, usually of sudden onset (10–20 days). It is treatable but requires urgent hospitalization.
3. Can health insurers reject claims for sudden illnesses?
No, insurers can only reject claims for diseases explicitly listed as pre-existing during the waiting period. Sudden onset conditions must be covered.
4. What is IRDAI’s role in insurance complaints?
IRDAI regulates insurance companies and provides a grievance redressal system for policyholders.
5. What is the Insurance Ombudsman?
An independent authority that resolves insurance complaints free of cost, within a time-bound framework.
6. Can consumers sue insurers in consumer court?
Yes, under the Consumer Protection Act, policyholders can seek compensation for deficiency in service and harassment.
7. How to prove an illness is not pre-existing?
Medical certificates, clinical history, and expert doctors’ opinions serve as valid proof.
8. Can liver abscess be considered pre-existing?
No, liver abscess is generally an acute condition and not classified as a pre-existing disease.
9. What is the cashless claim facility?
It allows insured persons to receive hospital treatment without paying upfront, as the insurer directly settles bills with the hospital.
10. What to do if an insurance claim is unfairly denied?
Escalate to the insurer, then IRDAI, then the Insurance Ombudsman, and finally consumer court if needed.
11. How much compensation can be claimed in consumer court?
Apart from reimbursement, consumers can claim mental harassment and litigation costs.
12. What documents are required to file a complaint?
Policy copy, claim forms, medical certificates, hospital bills, insurer’s rejection letter, and correspondence records.
13. Can policyholders approach the Ombudsman without IRDAI?
Yes, complaints can be directly filed with the Ombudsman after 30 days of insurer’s unsatisfactory response.
14. What is the time limit to file an insurance complaint?
Within 1 year of the insurer’s final response or rejection.
15. Can reimbursement be claimed later if cashless is denied?
Yes, patients can seek reimbursement claims after paying bills upfront.
16. Are all pre-existing diseases excluded permanently?
No, most policies cover pre-existing conditions after a waiting period of 2–4 years.
17. How can Choice4Voice.com assist in such cases?
By amplifying complaints, drafting legal templates, and guiding consumers in filing with the right authorities.
18. Can doctors’ opinions override insurer’s rejection?
Yes, medical certifications can be used as legal evidence against unfair claim repudiation.
19. What penalties can insurers face for unfair practices?
IRDAI may fine insurers, while consumer courts can order compensation for victims.
20. How can patients protect themselves against such issues?
By reading policy documents carefully, keeping medical history updated, and escalating complaints through official channels.
21. Is crowdfunding a solution in medical emergencies?
While legal battles continue, families often rely on crowdfunding platforms or public support to manage urgent expenses.
