Navigating the Twists and Turns with CARE Health Insurance. A Story of Challenges.
Our main character began this journey in June 2018 when they got a health insurance policy from CARE Health Insurance, a well-known player in the Indian insurance market. This policy, initially covering 5 lakhs, was arranged through their workplace, offering a sense of security against unexpected medical expenses. However, there was a significant missing piece in this transaction - the policyholder never received a copy of the proposal form or the detailed terms and conditions, which are essential for understanding such a significant commitment.
The turning point came in November 2019 when a health crisis struck, leading to hospitalization due to dengue. During this episode, CARE Health Insurance's performance was commendable. They efficiently and empathetically processed and approved a cashless claim, setting a positive tone for the relationship between the insurer and the insured.
Fast forward to November 2021, and our main character faced another health challenge, this time requiring planned surgery and hospitalization. However, there was a catch - the chosen healthcare facility was not part of the insurer's network. Consequently, the policyholder opted for a reimbursement claim.
This is where things got complicated. CARE Health Insurance unexpectedly rejected their reimbursement claim, a substantial sum of ₹6,07,000. The reasons for rejection were puzzling and distressing - the insurer cited "NON DISCLOSURE OF OBESITY" and "NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL."
Undeterred, the policyholder vigorously defended themselves, insisting they had provided truthful information during the policy proposal, including their complete medical history. Adding to the confusion was the insurer's adamant refusal to share the elusive proposal form, a document that could have shed light on this confusing situation.
But the complexity of this situation didn't end there. The policyholder continued to receive policy renewal notices from CARE Health Insurance, even after their claim had been rejected. Believing in the importance of insurance, they renewed the policy by paying the premium, only to discover an astonishing revelation - the insurer had abruptly canceled the policy, and they lost the premium they had paid. This sudden cancellation raised serious questions about the insurer's intentions and practices.
From a legal perspective, this case raised significant concerns. Insurance regulations and laws clearly state that insurers must provide policyholders with a copy of the proposal form and detailed policy terms within a specific timeframe. The rejection based on "OBESITY" was particularly puzzling since obesity is not typically considered a medical ailment requiring treatment.
Furthermore, the insurer's inconsistent handling of the case and the subsequent policy cancellation without proper notice left the policyholder in a vulnerable position. They were left without coverage during a critical time of health vulnerability, a situation that not only goes against various regulations but could also infringe upon the fundamental right to life guaranteed under the Indian constitution.
In their pursuit of justice, the policyholder has passionately called for a thorough investigation into their case, a resolution of their claim, and the involvement of regulatory authorities to prevent similar distressing situations in the future. They have also fervently requested access to the elusive proposal form and comprehensive policy terms.
As this story continues to unfold, it encourages us to reflect on broader questions about the insurance landscape in India. It underscores the urgent need for increased scrutiny and oversight to protect consumers from unnecessary distress and financial hardships. The story of this policyholder serves as a powerful reminder of the critical importance of transparency, fair treatment of policyholders, and strict adherence to regulations within the insurance industry. In a world where health insurance should provide a reliable safety net during challenging times, it is essential that such stories do not become the norm.
Disclaimer: The blog is based on the written complaint, supported by evidence submitted by the victim to the insurer. There is no intention to defame anyone named in this blog. The insurer also works relentlessly towards resolution of grievances, and we highlight these cases just to make others aware of prevalent insurance practices.
Now a days cases of rejection of health insurance claims are on the rise. Sometimes the reason quoted are flimsy. #IRDAI needs to tighten their regulatory monitoring of Insurance companies. They need to scrutinised rejected claims randomly. Like RBI/ SEBI, they need to impose penalties for regulatory violations.
ReplyDeleteWe have more dangerous and pathetic experience with care health insurance.A story much painful than this.Care deducted policy renewal amount even after the death of their customer,despite submitting death certificate,claim was under process.They keep asking one another documents for 18 months as NOC from other family members despite nominating sister in policy,they asked for affidavit,they asked for legal heir certificate and what not... to pay COVID death.At last they rejected the claim.
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