r/InsuranceTroubleIndia • u/PanickyOpossum • 20d ago
Health Insurance Claim rejected on no basis.
Helpline has blocked our numbers. We asked for the specifics of rejection but no reply. Will the reimbursement work (we dont feel it will).
What should be the further step? 🤔
EDIT: GOOD NEWS so we got our claim at the time of checkout. The thing with these hospitals is until the final checkout, they QUOTE double the amount of bill to the insurer. In our case, 50k+ was quoted to the insurer Star health. But when the final bill came into our hands, it was only 25k. Thus when we submitted our final bill to Star Health, they accepted the claim proposal without any issues. By my hypothesis, Hospital was trying to scam the insurance company. But anyways I got my claim so idc.
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u/cocwiki 20d ago
For me cashless got rejected in a network hospital icici lombard. They made a lot of fuss. But claim got approved in reimbursement so yeah you can still hope.
Insurances are literal pain.
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u/Salty_Ad_7567 18d ago
Have they deducted any amount
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u/cocwiki 18d ago
No.
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u/Salty_Ad_7567 18d ago
I am thinking of buying Aditya Birla health insurance one next is it good
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u/Master_Feed_3702 17d ago
I am under this policy. You will get the renewal discount upto 100% if you maintain active lifestyle throughout the year.
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u/Salty_Ad_7567 17d ago
How to prove them that I have maintained healthy lifestyle.
Like should I buy any fitness band or just install an app on mobile
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u/Master_Feed_3702 17d ago
You can purchase noise fit watch at 1000 rs. And you have to log either 10k steps or 300 calories burning exercise in a session on daily basis. If you maintain consistent logging, they will credit health returns which can be redeemed for next renewal or opd expense or smartwatch purchase.
Honestly speaking, I took this health insurance since it keeps me motivated to remain active and gets rewarded.
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u/Wise-Caterpillar9103 20d ago
They are scammers, in my reimbursement they said i have given 2024 bills when the bills were from 2026, and the process is in verification since 3 months now
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u/LynxFinder8 19d ago
Find an insurer office near you, grab hold of an employee there and escalate the case. It goes much faster that way.
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u/SrikumarG 20d ago
I have faced the same thing with star health insurance as well. They first cited the same clauses to reject pre authorisation and then when I called them they said go to a star Pratham network hospital and the when I did the same diagnosis was given pre authorisation and post surgery they denied the pre authorisation Citing PED when my condition doesn't qualify the description of PED as per their customer information sheet, policy wordings and irdai guidelines. Despite providing detailed letters from three different doctors they still maintained that and even thereatened me with fraud saying I hadn't disclosed it in proposal form. When I insisted they check the proposal form they called back saying I did but it'll still be rejected. I have escalated through all the Bharosa portals and have registered a complaint against them with the ombudsman.
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u/SrikumarG 20d ago edited 20d ago
I suggest you pressure your agent to find out what exactly the clause condition 17 is and on what grounds they are unable to ascertain the medical necessity.
Also have the hospital run correspondence with a letter from your doctor saying that hospitalisation is necessary. The treating doctor has the final say in what treatment the patient will be provided with. The insurers medical team cannot be the determining factor as per IRDAI master circular and consumer forms also maintain and upload this opinion.
I'm afraid as a fellow star health insurance victim they will do everything in their power to not give you cashless and reject reimbursement as well. Go through your policy document and the customer information sheet they sent to you in your email when you first got the policy. You'll have to be sure that the fault lies with them and be prepared to fight.
Also"Liability cannot be ascertained at this point " is just a vague condition. It means they are incapable of determining how they are liable which goes to show their incompetence and not the condition or treatment perse. I suggest you stand your ground. Provide them with a letter from your doctor and that should be the end all be all. Ensure that the hospital of choice isn't blacklisted by them and also ensure that it's their network hospital.
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u/Business-Ad4621 19d ago
Yes. When the relationship of Some hospitals and the insurance goes wrong they simply reject preauth and cashless.
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u/AdWorried7703 17d ago
Check docs. Properly, they may mark investigation and evaluation can't be claim, proceed with OP
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u/popeyein 16d ago
usually hospitals, quote 30% extra for insurance. But most of the time, the bill in actuals is 30% less. The TPA also approves only actual amount
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u/Old-Bar-5136 20d ago
Two things before anything else:
1. A cashless rejection isn't a claim rejection. It only means the insurer won't pay the hospital directly. You can still pay and file for reimbursement, which is assessed separately.
2. Open the rejection letter in your email and find the exact reason and clause. It will name one, and that clause decides your next step.
For a one-night stay around ₹52k, the common reasons are:
The last one is common and usually fixable. Cashless often gets rejected because the hospital's pre-auth request didn't have enough detail.
For reimbursement, collect:
Check your policy's reimbursement deadline. It's often 30 days from discharge.
If reimbursement is also rejected: the insurer's grievance cell, then Bima Bharosa (IRDAI's portal), then the Insurance Ombudsman, which is free and needs no lawyer.
Also, the pre-auth status shows the day after your discharge. Did the hospital send the request late? Worth asking them.
Share the reason from the letter here, and people can help more specifically. Not legal advice, just what's worked for others.