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Require help in hearing against Max Bupa Health Insurance at Insurance Ombudsman (Bimalokpal)

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09 Jul, 2021 by  Rahul Ajmera

Hello,


I'm Rahul Ajmera and I need help from experts in building a strong case to help me during my upcoming hearing with Bimalokpal (Insurance Ombudsman) against the wrongful rejection of my health insurance claim for Covid19 expenses by Max Bupa Health Insurance. My case is very simple, I had suffered from a mild case of Covid19, which was treated at home at minimal cost, for which I have requested for reimbursement. Given the pandemic situation and the non-availability of hospital beds, hospitalization was deemed unnecessary for this case. However, Max Bupa has taken a very negative stance towards my claim and rejected it in total, without providing any financial relief. I have taken Max Bupa's Health Companion Variant 3 family floater plan for my, myself, and my minor daughter. I do not have any special Covid19 related health insurance policy. My other family members have received compensation for their claims from Star Health Insurance for Covid19 home treatment without any hospitalization from their regular Health Insurance Plans.


Here is the Case History in Detail:

1.    Claim filed in October 2020

With reference to my Max Bupa health insurance policy no 30504055202004, I wish to lodge a complaint against rejection of my claim reimbursement towards domiciliary hospitalization during treatment of Covid19 for myself – Rahul Ajmera. I was tested positive on 18/09/2020 and tested negative on 07/10/2020 and during this period I was under the medical supervision of Dr. Mahendra V. Oswal and Dr. Bhushan Rathi (Remedy Diagnostics / Hospital. I had intimated Max Bupa Customer Care by email on 23/09/2020 regarding my treatment. I had also mentioned that due to the unavailability of hospital beds in Pune, it is not possible to undergo treatment at a hospital. Pune is the city with maximum Covid19 cases in India today, the local health infrastructure is so severely affected that young patients with mild symptoms without comorbidities are not even allowed for hospital treatment, as per the instructions of the local district authorities.

 

2.    Claim accepted in December 2020

I submitted my claim to Max Bupa on 28/10/2020 by post and email, which was ignored until I escalated the issue to the Max Bupa Grievance Redressal Team, who finally generated the claim ID #590724 on 11/12/2020, after almost 45 days since my claim submission.

 

3.    Claim Rejected in December 2020

On 29/12/2020, I received a Claim Rejection email, without providing any reasons for the same. I escalated the grievance to Max Bupa Grievance Redressal Team, who asked me to approach IRDA Grievance Call Centre or Insurance Ombudsman.

 

4.    Complaint escalated to IRDA Grievance Call Centre in January 2020

On 05/01/2021, I escalated the complaint to the IRDA Grievance Call, where after 3 months of correspondence with the Max Bupa team, it was communicated to me that I must approach the Insurance Ombudsman for resolution as my claim was rejected under the wrongful interpretation of the domiciliary hospitalization clause.


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3 Answer

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10 Jul, 2021

Reimbursement for home treatment expenses (domiciliary coverage) is given only when the medical condition of Insured is deemed fit for hospitalization but she is having to avail treatment at home due a) non-availability of beds at the hospital, and/or b) inability to be taken to hospital due a very severe health status.


Prima facie, I don't think your case fits into the requirements of domiciliary hospitalization as you have mentioned that you had a mild case of COVID 19.


However, your case papers will need to be looked at more closely if someone has to assist you with Insurance Ombudsman hearing. Two of my peers on this forum provide assistance in such cases - Anuj Jindal (Co-founder of Sure Claim) & Shailesh Kumar (Co-founder of Insurance Samadhan).


You can write to them at -


anuj@sureclaim.in

corporate@insurancesamadhan.com


Regards,

Asad

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10 Jul, 2021

Hey Rahul,


I agree with assessment of Asad. I can provide you free assessment of your case. If you can share details on anuj@sureclaim.in, I can evaluate and suggest a way forward. Alternatively, our friends at Insurance Samadhan can also provide you case assessment.


Anuj

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11 Jul, 2021

Dear Rahul

Your case need to be escalated in professiona manner , thrre is 70 % possibility that claim is payable if you were under active line of treatment of a hospital .

Please visit our website www.insurancesamadhan.com and reach us .

We guide aggrieved customer like you . Pl see many testimonials .

Shailesh

Insurance Samadhan

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