The policy under review was a ported health insurance policy with an inception date of 14 August 2025, with no exclusions and no pre-existing disease declared. The insured, referred to as Mr. A for confidentiality, is a practicing doctor in a reputed city, and his wife, Dr. B, is also a medical professional.
As per the allocation attachment, the date of admission was 20 September 2025 at 11:30 a.m. for a planned URSL (Ureteroscopic Lithotripsy) with DJ stenting on the left side for left renal calculus.
The first diagnostic document submitted was an ultrasonography report dated 18 September 2025. This report mentioned a renal calculus measuring 11.4 mm located in the lower pole of the left kidney. The report did not mention the patient’s age, and no USG plate was provided along with it.
The hospital insurance claim form showed that the patient signed at 2:59 p.m. on 20 September 2025.
Video verification was conducted on 20 September 2025 at around 6:00 p.m. The call was initially attended by the patient’s wife, Dr. B, who stated that the kidney stone size was approximately 15
mm. The patient was then shown lying on the hospital bed, covered with a cloth, and stated that he was in pain and unable to speak properly. He further stated that the surgery had already been completed, and informed that the procedure started at around 1:00 p.m. and ended by approximately 3:30 p.m.
This statement conflicted with the claim form signature time of 2:59 p.m., which falls within the alleged operative period.
After video verification, the patient shared a CT scan document. On scrutiny, it was found that the document was in an editable Word format, without any diagnostic centre name, doctor’s signature, stamp, or authentication. This document mentioned the date of investigation as 19 September 2025 and reported a renal calculus measuring 12.4 mm at the pelvic ureteric junction (PUJ).
Subsequently, the patient shared separate photographs of CT plates without any date. One image showed a stone size of 11.88 mm, while another image showed 10.88 mm. No complete dated film or consolidated report was provided.
On comparison of all medical documents, the following sequence emerged:
On 18 September 2025, the stone measured 11.4 mm and was located in the lower pole of the left kidney
On 19 September 2025, the stone measured 12.4 mm and was shown at the pelvic ureteric junction
On 20 September 2025, the stone size was verbally stated as 15 mm during verification
Additional two separate plate images without patient’s name and date showed stone sizes of 11.88 mm and 10.88 mm
From a medical perspective, movement of a renal calculus from the lower pole to the PUJ within one day without documented clinical events is clinically unlikely. From an insurance perspective, the presence of multiple stone sizes, inconsistent locations, unauthenticated reports, and conflicting timelines raised serious doubt regarding the authenticity of the medical records.
Considering the insured’s medical background, such discrepancies could not be treated as inadvertent errors. Based on the cumulative inconsistencies, the claim was assessed as suspicious and not admissible, and was therefore repudiated as per policy terms.