Denial of claim by health insurance company
Niraj Kumar Mishra
(Querist) 18 July 2015
This query is : Resolved
Dear Sir,
i NIRAJ KUMAR MISHRA , HAVE INSURANCE POLICY OF STAR HEALTH.(WITH LAST 5 YEARS)
I HAD HOSPITALISED(CASHLESS) DUE TO CHEST PAIN , AND DURING PROCESS DIGONISED BP ALSO, DURING INVESTIGATION (ECG, ECO, XRAY, CARDIAC ENGIOGRAPHY(CAG), FIND NOTHING , AND WHEN I CLAIM AT THE TIME OF DISCHARGE , STAT HEALTH REJECT MY CLAIM STATING REASON " patient admitted only for evolution only" hence claim rejected.WHAT RIGHT I HAVE LEFT , PLEASE SUGGEST ME .
YOURS
niraj
7488566899
Kumar Doab
(Expert) 18 July 2015
What is the report written written by doctor that referred you to hospital, and the doctor in hospital at the time of admission in hospital and in discharge summary?
Did the doctor record elevated/reduced levels of BP and that it demanded further diagnostics tests?
Show these, proposal form, and policy of each year to your lawyer specializing in consumer cases and further advice.
Advocate M.Bhadra
(Expert) 18 July 2015
You need to lodge a written complaint addressed to the Insurance Ombudsman of your jurisdiction. You can find the insurance ombudsman of your jurisdiction through the document provided at the time of buying the policy or by referring to the IRDA website.
If the matter is settled, Ombudsman makes recommendations that are fair to the case. He has to make those recommendations within one month and send the copies to you and to the insurance company.
You have to send his reply saying whether or not he has accepted the settlement within 15 days of the recommendations. If the Ombudsman has recommended that the person complaining gets an award then the insurance company is bound to pay it. The payment has to be made within 3 months of the receipt of the recommendation.
If the recommendations of ombudsman do not satisfied you, then you can send a reply rejecting the recommendation to both the ombudsman and the insurance company.
You can then approach other forums like Consumer Forum or Civil Court,but best option is go to Consumer Forum/Commission.
Niraj Kumar Mishra
(Querist) 18 July 2015
thanks sir, but what my case shows . million dollor's question is that why we buy a health insurance policy. for better preventation or waiting for the deasese to spread to advance stage . i do not suggest to doctors to perform a test, they have done for me so if there is find nothing,
it means insurance company's intention is get deaseses first than claim, so this is totally against soul of HEALTH INSURANCE concept
Kumar Doab
(Expert) 18 July 2015
You have posted that:
"STAT HEALTH REJECT MY CLAIM STATING REASON " patient admitted only for evolution only" hence claim rejected"
1. Who has rejected the claim::: Insurance Company or TPA?
2. Write to the Insurance company that TPA/Insurance Company has grossly erred as you did not visit for so called evolution and it was doctors diagnosis to treat you properly.
3. Show proposal form, and policy of each year, rejection of claim, admission report,discharge summary etc. to your lawyer specializing in consumer cases and further advice.
M/s. Y-not legal services
(Expert) 18 July 2015
first you have to clear the terms and conditions for your policy.. if any violation against the terms mean you can proceed legally against the insurance company..
-M/s.Y-not legal services-
J K Agrawal
(Expert) 19 July 2015
Generally the only diagnosis Charges not covered in policy. You should be admitted at least for 24 hours and for Treatment of some ailment.
Rajendra K Goyal
(Expert) 19 July 2015
The Insurance companies reject the claims on small and flimsy grounds. All person does not go to court for rejected claim and the company escapes paying claim. who care for the damage to reputation when they have selling team bluffing the customers and earning commission and business for the company.
For pressuring the claim agree with the expert Advocate M.Bhadra.
Niraj Kumar Mishra
(Querist) 20 July 2015
stat health Insurance company has rejected the claim
MY insurance policy has the only permanent exclusion, WHICH CAN'T cured medically
i am planning claim once more , if they reject again , than i am planning to sue on them, my policy is 5 year old without break
Niraj Kumar Mishra
(Querist) 20 July 2015
i had admitted on 14/7/15 and discharged on 16/7/15
Kumar Doab
(Expert) 20 July 2015
Consult with an able lawyer specializing in consumer matters.
