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10 Nov, 2023 | Health Insurance

Claim Stories: Why it Pays to Read Between the Lines!

Debdyuti Roy
By Debdyuti Roy
Creative Content Writer at Beshak
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There are two types of people in this world: people who click on “I have read and agreed to Terms and Conditions” without actually reading them and liars. And let’s be honest, we all have been guilty of the same, especially with insurance. While the benefits/features of a policy are mentioned in big, bold letters, the fine print, the important stuff are mentioned with asterisks. And most of us don’t find the time nor interest to read between the tiring lines.

But insurance is largely an investment, a long-running commitment to a better future. And here, you absolutely cannot take the risk of not delving into the fine print and T&Cs.

Why? What’s so important hidden there?

Put your reading glasses on! And let's dive into Mr. Akhil Arora's real-life insurance claim story to answer your question. 👇

The Facts of The Case

On November 20, 2019, Mr. Akhil Arora faced a challenging situation. His spouse, Mrs. Manisha Arora, was admitted to Medanta Medicity due to an illness. Concerned for his wife's well-being, Mr. Arora followed all the prescribed procedures. And heeded the advice of the treating doctor - who recommended a 24-hour continuous ECG monitoring to diagnose the root cause of the illness. This procedure could only be conducted under In-Patient Department (IPD) hospitalization.

Mr. Arora hoped his insurance policy would cover the expenses incurred during this hospitalization. But to his surprise - his claim was rejected by the insurance company!


Well, the insurers cited something called - "general definition no -12", and said that the treatment went against it. "General definition no -12" states that:

The Insurer's Stand

The insurance company argued that the hospitalization was primarily for diagnostic purposes. They pointed out that the patient received only a tablet called Pansec 40 mg during her hospital stay. Pansec is used to reduce stomach acid and promote healing in cases of ulcers and acidity-related disorders. The insurer maintained that no therapeutic treatment was administered during the hospitalization, and the patient could have been managed on an Out-Patient Department (OPD) basis.

Furthermore, the MRI brain and VEEG reports came back normal, indicating that the hospitalization was mainly for evaluation rather than treatment. Based on these grounds, the insurer rejected the claim, asserting that it did not align with the policy's terms and conditions.

Mr. Akhil Arora strongly disagreed with the insurer's decision. He argued that his wife's hospitalization was carried out in accordance with the doctor's advice and further requested payment for her treatment.

The Verdict?

After carefully reviewing all the documents and hearing the arguments from both parties, the Ombudsman noted one important point - Mr. Arora's complaint stemmed from the insurance company's claim denial on the basis of "active treatment".

Upon examining the discharge summary from Medanta Medicity Hospital, it became evident that the primary reason for Mrs. Arora's admission was for investigation and NOT for therapeutic treatment. Her MRI brain and EEG results were both normal, and she was prescribed only Pansec. This led to the conclusion that the hospitalization was primarily for diagnostic purposes.

In light of these findings, the insurance company's decision to reject the claim was deemed justified, and no intervention was deemed necessary. Thus, Mr. Akhil Arora's complaint was, unfortunately, dismissed, and no relief was granted.

Learnings From The Case

Mr. Akhil Arora's insurance claim journey serves as a reminder that a deep understanding of your health insurance policy is essential.

Yes, it’s important to know about your policy benefits and what it covers. But it’s also equally important to know the hidden conditions, what it won’t cover.

When you or your loved ones are already battling health issues, the burden of insurance claim not getting settled shouldn’t get added up. So carefully assess the fine print of your policy beforehand.

👉Remember, for your claim to get approved - the treatment should be in-line with standard medical protocols. 

👉It must be clearly recommended by a medical practitioner, who is not related to you. Seek a second opinion, if needed.

👉Note that the hospitalisation should involve an active line of treatment. It has to be established in writing that the treatment cannot be carried out at home. For instance, treatment that requires only observation and oral medication may not be covered.

👉The treatment should be for the purpose of curing the health condition or symptom of the patient, and not just for observation or tests. Otherwise, you may have to foot the bill yourself.

By being informed and making the right choices, you can actually let health insurance solve its purpose. The purpose of taking that financial stress away from you in the hour of need. :)

Want to decode all the hidden fine print in your health insurance plan? Beshak Fine Print Decoder got your back!

Key takeaways
  1. Mr. Akhil Arora's story highlights the significance of understanding your health insurance policy terms and conditions.
  2. Hospitalization primarily for diagnosis or monitoring may not be covered under health insurance.
  3. "Active treatment" is a key factor in determining insurance claim eligibility.
  4. Explore the option of home-based care for conditions that only require observation and oral medication to avoid unnecessary hospitalization expenses.
Debdyuti Roy
Debdyuti Roy, Creative Content Writer at Beshak

Debdyuti merges her English major proficiency with insurance creativity. Beyond crafting engaging narratives, she leads an NGO, reflecting her deep commitment to helping others. With words as her tools, Debdyuti transforms insurance into a relatable and impactful journey, making a positive difference in both her writing and philanthropy.

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