Nikhil Jha

Background:- A family of four Ram,his wife and two children bought Medical Insurance in 2018 with a Sum insured of 50L They were paying a premium of Rs 25,000/year towards this policy.

In April 2024, Ram was diagnosed with severe dehydration and kidney creatinine levels became pretty high The doctors were very alarmed by this situation and it necessitated admission to Max Super Specialty Hospital, Mohali.

Ram had to be kept in medical management for 4 days. With the doctor giving him medication to manage the creatinine levels, In the meanwhile, Ram contacted his insurer to get cashless claim approval, To the family's surprise, The insurer rejected the claim stating "Hospitalisation not needed and could have been done on an OPD basis"

The family argued, That hospitalization was advised by doctors and he did take the step himself. He also presented the written letter from the doctor stating the patient was in a critical condition and the hospitalization was necessary The insurer maintained that they did not feel that the hospitalisation was really necessary.

Ram's family paid the entire bill and got the discharge done Over the subsequent months, The father approached the insurer time and again to claim back the money So the insurer rejected the following claims 1. Cashless claims 2. Reimbursement claim 3. Grievience 1 4. Grevience 2

When the insurer was unwilling to listen, Ram approached the ombudsman During the hearing, The father put forth his case saying the situation was bad and the doctors had advised hospitalisation. The insurer took the view that the reports did not warrant any hospitalisation and this could have been treated on an OPD basis.

After hearing both sides, The ombudsman ruled, The insurer cannot reject the claim by arbitrarily stating that hospitalization is not needed. If the treating doctor had advised hospitalization based on certain parameters. The insurer should not challenge it.

The ombudsman also fined the insurer for causing mental agony to Ram On top of this, the ombudsman also charged an interest rate of 10% on the amount and asked the insurer to pay the amount with interest! The insurer went ahead and accepted the ruling of the ombudsman and paid the amount within 7 days of the ruling.

So what are the key takeaways? 1. Always get hospital admission only when the treating doctor advises you to do so. 2. Insurers reject claims at will.Have patience and follow the process which is laid down by IRDAI (in case of claims rejection) 3.Always have a good agent assist you.A good agent can be the difference b/w claims being passed and rejected

4. Necesitty of hospitalization is a vague clause that insurers use to reject claims. Be very careful about this clause.

Thanks for reading😁😁😁 The idea of claims stories is to bring out the reasons of claim rejection and how u can save urself from painful rejections If you liked this thread then "Retweet" the first tweet Follow me @NIKHILLJHA as I write deep insights into health insurance Go to my profile and hit the bell icon🔔to always stay updated