I have taken Health Insurance for my mother from Policy Bazaar.
Care Health Insurance is the health insurance company.
Policy number: 78537850.
On 25th July, 2024 mother had difficulty in breathing. We consult doctor via video calling and he prescribed medicines and some test. We gave her medicines but in the next morning breathing problem persists. So we take her to emergency Ayushman Hospital, Dwarka Sector 10, Delhi.
We gave her insurance card to the TPA and the process for cashless begins.
She is still in ICU.
Hospital running bill around Rs 6, 70, 000.
Insurance company raise the following query:
1. Patient is bedridden from past 1 year. Provide treatment record for bedridden.
2. Provide previous records for COPD and Heart failure.
On 29th July, In the response to Query, Doctor and the hospital gave the necessary reply. For bedridden, Treating doctor Dr. V K Raju mentioned that the patient has knee pain and she is heavy built too, due to which she have difficulty in walking and prefers to be in bed. She is not bedridden.
Also she has no previous history of COPD and heart failure.
But insurance company denied the cashless claim asking for the bedridden history.
For reconsideration of claim, On 31st July, Doctor gave the necessary reply and I have attached my Self declaration.
Despite this, insurance company again denied the claim asking again and again for the bedridden history.
I have called the Policy Bazaar to support me in this time of adversity and help in the claim process.
But unfortunately, Policy Bazaar stands for the Insurance company.
I have recorded all the conversation.
Role of Policy Bazaar and their false assistance of onground support for the claims raised:
Policy Bazaar executive told me the following reasons for my cashless claim rejection:
1. On 26th July, when the patient admitted in emergency, your doctor mentioned that patient is bedridden from past 8 - 10 months. Also on indoor case papers, somewhere on 28th July also, doctor mentioned the term bedridden.
When I asked him to Provide the papers on which doctor has written bedridden. He only gave me the paper of 26th July.
On 26th July, emergency doctor Dr Kuldeep used the term Bedridden as we have told him that she has knee pain and difficulty in walking, so she prefers to be on bed.
He made a note on it and write that the patient is bedridden from past 8 - 10 months. It’s a general term he used for it.
But when the insurance company raise query for bedridden , treating doctor gave the necessary reply that she is not bedridden.
PB executive stick on that note of emergency synopsis taken by emergency doctor and states that your doctor (Treating doctor) is giving different reply to the query Raised on bedridden.
Despite my full explanation, he denied to admit the doctor’s reply.
2. Executive told me the second reason for rejection that the medical team of Care Health Insurance has findings of previous COPD and heart failure.
I told him that doctor already mentioned on reply letter that the patient has no previous history of COPD and heart failure on 29th July as well as on 31st July. Also in my Self Declaration, I also mentioned that my mother is not bedridden and she has no previous history of COPD and heart failure and she has never taken any treatment regarding to this.
Despite this, he told me that the insurance company has findings regarding COPD AND HEART FAILURE and you have to Provide that details.
Now,
> I asked him to Provide the finding that Care Insurance medical team has regarding COPD and heart failure.
He denied that he can’t Provide patient medical findings and he is not authorized for that.
> I asked him to give written declaration what Insurance Company gives reasons for rejection from registered mail ID of Policy Bazaar as Policy Bazaar is my Broker.
He denied to give it too.
> I asked him to Provide my declaration of pre existing disease which I told Policy Bazaar during the purchase of policy as I told them on recorded lines.
He denied.
Resolution by Care Health Insurance:
Contacted the helpline number and they provide the following reasons for rejection of cashless claim:
1. Patient is bedridden from past 1 year. Provide treatment record for bedridden.
I explained all this on recorded line.
2. Provide past history of COPD and heart failure.
I explained all this that the doctor has already given the necessary reply regarding this and also I had attached my Self Declaration.
Despite this, they told me your claim for cashless is closed and you can go for reimbursement claim.
I told the insurance company that for reimbursement, I have to pay the bill first which I can’t afford right now as it is an unplanned hospitalisation.
I asked him if there is any fault or non disclosure of anything by my side, then cite the reason and reject my claim and don’t even consider for reimbursement else approve my cashless claim.
But they denied.
Contacted the Care Insurance Dwarka Sector 5 branch for immediate intervention on 2nd August along with my lawyer, but they told me that we have reopen the case , mentioned the details and the decision will come around 2 hours.
I had waited the whole day and on 3rd August, called the customer care for the case reopen status, they said we don’t have any such reopen request and your claim is still rejected.
On 3rd August, I visited the Care Insurance Head Office, Gurugram.
I asked for my claim status.
Person from the Sales Team (as told by them) gave me different different reasons one after the another for the rejection.
1. He told me that your uploaded documents are not complete and we have not received the proper answer to our query Raised.
When I told him that the doctor has already given the necessary reply. He go inside and after sometime came back and told me the another reason for rejection.
2. He told me that your current illness is due to pre existing disease - diabetes and hypertension due to which patient heart fails.
When I told him that the patient has Pus in uterus as diagnosed in MRI due to which Infection in blood occurs called Septicemia. Septicemia results in Acute renal failure and heart failure.
Pus in uterus can happen due to many reasons. It is not only due to pre existing disease diabetes.
He again go inside and come back and told me to Provide justification for Osteoporosis and its treatment.
3. I asked him to raise a query and we will provide whatever required.
He again go inside, come back with a new reason that the doctor’s reply paper has only stamp of hospital, not of the Treating doctor. I told him that we again provide the doctor’s reply with doctor & hospital stamp.
He go inside and Raised a query letter with the following details asked:
1. All hospital papers, indoor case history with all investigations done etc.
2. Treatment record for diabetes, hypertension, backpain, Osteoporosis, Orthoarthritis.
3. Pre hospitalisation OPD treatment record.
We assured him to Provide all the documents asked.
Mother admitted on 26th July, 2024 Afterwards diagnosed with renal failure, heart failure, high potassium and low sodium level. She was on ventilator.
Now On 3rd August, 2024 when we visited headoffice for our claim reconsideration request after 8 days of admission and after rejecting our claim twice , they Raised a new query asking for pre existing diseases treatment record.
We started gathering treatment records. After sometime, we received the message that your claim is rejected due to pre existing diseases.
Also it came to our notice that the medical team of Care Health Insurance cited Pus in uterus which results in Septicemia is only due to uncontrolled diabetes.
Pus can also develop in any body who is non diabetic.
It is nowhere stated that Pus can develop only due to uncontrolled diabetes.
Rejection letter issued by Care Health Insurance states that :
Pre existing disease and its complications are covered after 2 years waiting period.
Medical team has not given any clear clarification that :
Pus in uterus results in Septicemia is the only and direct complications of diabetes and hypertension ( Pre existing disease in our case)
This is truly a case of harassment.
My humble request to everyone please share this post to your relatives, your loved ones, your near and dear so that we can protect the people from the cheating, harassment and mental trauma which I am facing right now due to entities like:
Policy Bazaar and Care Health Insurance.
We have to collectively fight for all these types of genuine cause of claims which draconian entities like these do to the people in this time of adversity.
Thank you and help me....!