back arrow Back

Health Insurance not allowing me to file my claim!

reply Share
21 Jun, 2022 by  Vishal Waghmode

I bought an HDFC ERGO health insurance. My father was hospitalized and was operated on for Angioplasty we got the pre-approval from the company but during the discharge, the hospital made a mistake and sent the wrong discharge summary in my father's name. The insurance company used this discharge summary to reject my claim and I immediately called and told them Hospital must have made a mistake please hold the claim process until the new documents are provided. They didn't listen.

The next day, the hospital sent the new discharge summary and an apology letter stating the mistake. They still rejected the claim stating they need more time for an in-depth investigation and asked me to come for reimbursement.

Now while applying for reimbursement I found out that basis on the wrong discharge summary the company has decided to terminate my policy and has changed the start date of the policy so that I can't file a reimbursement.

So because of one wrong discharge summary sent by the hospital I am facing all sorts of problems

  1. Cashless claim rejected
  2. Can't file for reimbursement
  3. The policy will be canceled in 10 days.

Please help me with how can I get the claim amount(4.3L) and continue my policy.

like like
0
Claim

3 Answer

Post
21 Jun, 2022
We breathe insurance :)

Hello Vishal,


This is pretty unfortunate. We cannot imagine how frustrating this can be.


It looks like the claim was payable since you did receive the pre-authorization. Now, if the issue is only about a mistake by the hospital, then as a first step, you must contest this through the grievance mechanisms available, so that this policy can be reinstated and the claim be paid.


We would strongly recommend that you file a grievance with the insurance company and immediately with IRDAI.

Here are some links:

HDFC Grievance: Grievance Redressal Procedure - HDFC ERGO

IRDAI Grievance Grievance Cell (irdai.gov.in)


Do keep us posted


We are also getting other experts on the panel to share any additional guidance/tips that may help


Team Beshak

like like
0
icon-comment 0 Comments
icon-reply Reply
21 Jun, 2022
We breathe insurance :)

We spoke to another expert and here's what is their response:


They cannot cancel without giving notice as per policy and giving the opportunity for the insured to respond, in case the cancellation is on account of fraud or non-disclosure.


There is also another suggestion to write a detailed email to the CEO/Sr. Management

like like
0
icon-comment 0 Comments
icon-reply Reply
29 Jun, 2022
connect with advisor

Dear Mr.Vishal,


We can understand what you must be going through during this situation. Despite the fact that the Health Insurance Industry has come a long way in terms of making their products & services seamless, we still come across such exceptional cases where clients do share their bitter experiences. Please understand the following important aspects pertaining to pre-authorization (initial approval) and the final approval mechanism:

1.Initial Approval is given based on the primary information shared by the hospital & is conditional. If during discharge, it is found that there was a misrepresentation or material facts being hidden, the approval shall stand null & void.

2. However, in this case, if you are sure that all material facts about your Father's health were declared in a fair & transparent manner at the time of policy inception, be rest assured, Your Claim would get settled and policy termination decision too shall be called off by your insurer.

3. Policyholder can not be held responsible for a mistake committed by the hospital and atleast not after the hospital has admitted the error and shared the accurate documents. In such cases it's the primary responsibility of the insurance company to do due diligence before coming to such a conclusion

4. Trust me, Hdfc Ergo has been a responsible insurer & has a repute of being a policyholder friendly company. This could have been a result of communication gap and I'm sure would get resolved in due course of time.

5. As suggested by Team Beshak first step is to immediately approach the insurer through the Grievance Redressal & if you fail to get proper response from the insurer, you have every right to get the issue resolved through Insurance Ombudsman. IRDAI plays a very active role in safeguarding the interests of the policy holders.

Also you could seek the help of Insurance Samadhan through: https://www.insurancesamadhan.com/


Check the following article on the process to approach insurance ombudsman.

https://www.google.com/amp/s/www.livemint.com/money/personal-finance/how-to-get-your-insurance-related-complaints-resolved-through-ombudsmen/amp-11636715941386.html


Have trust in the insurance mechanism & I'm sure you would rightfully get what you deserve.


Hope this helps you & keep us informed


Satish Kumar H



like like
0
icon-comment 0 Comments
icon-reply Reply

Tired of dealing with call centers!

Get a professional advisor for life!

Rs. 1799

LIFETIME FREE

Lifetime Free

or

Discover the best tips for insurance every week!

Beshak is not regulated by the Insurance Regulatory and Development Authority of India (IRDAI) and does not have any alliance or association with any Insurance business.
© Copyright 2022 Beshak Solutions Pvt. Ltd. All Rights Reserved.

Disclaimer: The content on the website is purely for information purposes for the public at large, and does not constitute personal financial advice for a specific individual reader.
If you are reading this, it means you love reading the fine print. Why not get paid for what you love doing - Join us by writing to info@beshak.org now 🙂