When insurance fails: A year of struggle over a critical health claim
Published by India Today
Abhishek Kumar's role: Quoted
Abhishek Kumar explained that such cases are common and set out an escalation path: keep records, seek written reasons for a denial, approach the insurer's grievance desk, then the Insurance Ombudsman and consumer court. He cautioned that resolution can take months.
What Abhishek Kumar said
What should I do first if my health insurer refuses a claim?
Sadly, cases like this are common. I suggest keeping a record of everything from the first day: bills, reports, letters and every message exchanged with the insurer. For cashless treatment, seek pre-authorisation. If the claim is turned down, ask the insurer to give its reasons in writing and to name the policy clauses it is relying on. That written reply is what you will need when you escalate.
Where can I escalate a rejected health insurance claim?
I would begin inside the insurer, first with its grievance desk and then with its nodal officer. If the matter is still open after 30 days, raise the matter on the Bima Bharosa portal and take the case to the Insurance Ombudsman. If that does not settle it either, you can still go to the consumer court. Each step builds on the written record you have kept.
Can a health insurer cancel my policy without notice?
Under IRDAI rules, an insurer may cancel a policy only after it has established fraud or misrepresentation, and it must give at least seven days' notice. If your policy has been cancelled, file a grievance with the insurer and ask for the policy to be reinstated. If that is not resolved within 30 days, take it to the Ombudsman and, where needed, to the consumer court.
How long does it take to resolve a disputed health insurance claim?
IRDAI has tried to lift insurers' service standards, requiring a decision on cashless authorisation within one hour and discharge approval within three hours. In practice, though, a disputed claim can take months to resolve. In my view, insurers often wear down aggrieved policyholders in the hope that they will give up on the claim, so be prepared for a long follow-up.
In our words, from what he said in the piece. General information, not personal advice.
More of Abhishek's views on insurance
Part of a series on rejected health insurance claims, the article follows a family's year-long effort to get a heart treatment claim paid after the insurer cited non-disclosure of an existing illness. It covers the Insurance Ombudsman's role, the partial settlement, and the steps policyholders can take when claims are denied.
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When insurance fails: A year of struggle over a critical health claim