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claim rejection by hdfc ergo

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20 May, 2021 by  investmentpoint10

one of my client approached for the pre-approval from the hdfc and after they approved pre-hospitalization then client was admitted to hospital and at the time of discharge company rejected the claim stating that it is rejected due to exclusion standard terms and condition and client has applied the claim first time 8 years down the line.


the claim amount was 50000/- so please help on this matter as urgent as possible.


Regards,

Rahul Goyal

7838570000

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2 Answer

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20 May, 2021

This usually doesn't happen. An Insurer gives pre-authorization for settlement of hospital expenses only when they are fairly sure about admissibility. In case of an iota of doubt, the Insurer usually declines pre-authorization & asks the policyholder to pay first and then file for reimbursement.


The only plausible reason for rejection of claim could be there is a new material fact (mentioned by the patient at the time of availing treatment) that wasn't disclosed by the Insured at the time of policy inception.


You should advise your client to file for claims reimbursement by providing all hospital bills, indoor case papers and supporting documents again.


If you parallely want to take professional opinion on your claim, please write to anuj@sureclaim.in.


Regards,

Asad Akbar

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21 May, 2021
investmentpoint10
Thanks for replying,but the line of treatment and pre-authorization was same and no other treatments was taken so please update how can the claim can be taken as hdfc grivence department also rejected the claim on request made to them.
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21 May, 2021
This will require a closer look. Please write to anuj@sureclaim.in with all details of the claim. Anuj Jindal is a fellow contributor to this forum. He also runs a claims consultancy by the name Sure Claim. He could be helpful to you.
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19 Jun, 2021
Thanks Asad for recommending Rahul to write to me. The patient had undergone Tubal Ligation surgery, which is excluded from the policy. I am guessing there was manual error in approving pre-authorization, but very correctly the claim was rejected later on. Pre-authorization is not a promise for claim approval, so client cannot hold insurer accountable for pre-authorization of cashless and later rejection. Anuj
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20 Jun, 2021
Anuj, thanks for pointing out the matter. I believe this will help the Insured take informed next steps.
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31 May, 2021
investmentpoint10

sir sent the Mail to Mr Anuj but no reply received pls help

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18 Jun, 2021
investmentpoint10
sir no reply received from Mr Anuj.
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20 Jun, 2021
Hi, Anuj has replied to you on this thread above. Please refer to his response. Thanks
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