Injustice Unveiled: The Care Health Insurance Claim Denial Controversy Shakes Trust in Health Coverage

 

The Case of Unjust Health Insurance Claim Denial by Care Health Insurance

Introduction

In recent times, a concerning case of health insurance claim denial has emerged, shedding light on the challenges policyholders face when dealing with insurance companies in India. While the policyholder involved wishes to remain anonymous, the details provided are essential for understanding the issues at hand. This case centers around the alleged illegal denial of a health insurance claim under the 'Critical Mediclaim' policy offered by Care Health Insurance Co Ltd.

The Policyholder's Journey

In October 2020, the policyholder was approached by a representative from Care Health Insurance. The representative presented the 'Critical Mediclaim' policy, assuring the policyholder that it would cover all future hospitalization expenses related to specified critical illnesses without requiring out-of-pocket payments. Additionally, a premium discount was offered for a three-year policy term.

The policyholder, after a comprehensive discussion, decided to purchase the policy, disclosing their tobacco-chewing habit. The policy was issued with a sum insured of 10 lakhs, effective from October 11, 2020, to October 10, 2023.

Health Crisis and Claim Denial

In January 2023, the policyholder received a cancer diagnosis and underwent treatment at "Nargis Dutt Memorial Cancer Hospital." Subsequently, in February 2023, further treatment was sought at "Vivekanand Cancer Hospital, LATUR," which was within Care's cashless network.

However, Care Health Insurance denied the cashless request for the second hospital without providing a clear explanation. This unfortunate situation led the policyholder to delay their treatment and seek assistance from a government hospital.

A reimbursement claim was subsequently filed for the first hospitalization in May 2023, amounting to INR 82,624. Regrettably, the claim was rejected, citing "PERMANENT-EXCLUSION -CONDITION CAUSED BY SUBSTANCE ABUSE AND NONDISCLOSURE OF CVA AT THE TIME OF POLICY INCEPTION."

The Policyholder's Concerns

The policyholder has expressed several significant concerns in response to the claim denial:

1. Non-receipt of the proposal form: As per IRDAI regulations, insurers are obligated to provide a complete proposal form to the customer within 30 days of acceptance. In this case, the policyholder never received a copy of the proposal form, raising questions about accusations of non-disclosure.

2. Lack of detailed policy terms and conditions: The policyholder was not provided with a copy of the comprehensive Policy Terms and Conditions, which is a breach of the Insurance Act and the Consumer Protection Act.

3. Unsubstantiated claim rejection: The claim denial was based on conjecture, with no documentary evidence of non-disclosure provided.

4. Incorrect application of exclusion clauses: The claim denial cited an exclusion for "Alcoholism, drug, or substance abuse," despite the policyholder receiving treatment for cancer, which is explicitly listed as a "Covered condition" under the policy.

5. Inadequate disclosure of exclusion and pre-existing disease conditions: The Customer Information Sheet did not mention any "Permanent Exclusion," and "Pre-existing disease" was declared as "NONE." "Cancer" was also prominently listed as a "Covered condition."

6. Lack of evidence linking tobacco chewing to cancer: No medical evidence was provided to prove that tobacco chewing inevitably leads to "Cancer."

7. Denial of rightful services: Despite paying substantial premiums and having a valid policy, the policyholder was denied services without valid reasons, constituting "Deficiency in service" and "unfair trade practice."

Conclusion

This case highlights the need for a thorough investigation into the claim denial and emphasizes the importance of transparency and fairness in insurance practices. The policyholder seeks a comprehensive investigation and the processing of their reimbursement claim along with applicable interest. Failing to address these concerns may lead to further escalation of the matter to relevant authorities and consumer organizations.

The principles of fairness, honesty, and transparency must prevail in the insurance industry to protect the interests of policyholders. This case serves as a reminder of the importance of holding insurance companies accountable for their actions and decisions.

Please share this story to raise awareness about such issues and encourage a more just insurance system in India.

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.