In the increasingly complex world of health insurance, senior citizens often find themselves grappling with overwhelming challenges, especially when it comes to making legitimate claims. The case of Mr. S.P. and Mrs. V.P., senior citizens who purchased a health insurance policy through Bajaj Finance Ltd., highlights the distressing reality many face due to the unlawful practices of some insurers.
The Backstory: A Promising Start Turns Sour
In 2019, Mr. S.P. was approached by Bajaj Finance Ltd. with an offer to enroll in a group health insurance plan under Aditya Birla Health Insurance Co Ltd (ABHI). The proposal was appealing – a comprehensive ‘Group Activ Health’ insurance policy with coverage of ₹2 lakhs, without any upfront premium payment. The premiums were to be paid via EMIs, making it seemingly convenient. However, the cracks began to appear early on when Mr. S.P. was not provided with a proposal form or detailed policy terms and conditions. Despite disclosing his pre-existing condition of hypertension, the critical documents remained out of reach.
In 2020, Mr. S.P. requested the inclusion of his wife, Mrs. V.P., in the policy. At that time, she had no pre-existing conditions. However, her inclusion did not come with the transparency one would expect from a reputed insurer like ABHI.
The First Signs of Trouble: A Health Crisis and an Incomplete Disclosure
In April 2021, Mrs. V.P. suffered a brain stroke, leading to her hospitalization at XYZ Hospital in Delhi. During this period, she was diagnosed for the first time with Type-II Diabetes and Hypertension. ABHI settled the claim on a cashless basis without any issues. However, the peace was short-lived. A second hospitalization followed shortly due to her deteriorating health, where she was diagnosed with Coronary Artery Disease (CAD) and Hypertension. ABHI once again settled the claim and even approved a post-hospitalization claim.
The policy was renewed continuously, and all existing medical conditions were duly declared during each renewal. Bajaj Finance, acting as the master policyholder, recorded these details accurately, yet the documents detailing these renewals were never provided to Mr. S.P.
November 2023: The Saga of Claim Rejection Begins
In November 2023, when Mrs. V.P. was diagnosed with a xxxx xxxxx requiring urgent surgery, a cashless request was submitted to ABHI by the hospital. Shockingly, the request was rejected without any explanation. Forced to pay the hospital bills out-of-pocket, Mr. S.P. submitted a reimbursement claim, only to be informed that Diabetes and Hypertension needed to be updated as Pre-Existing Diseases (PED). This was despite ABHI already being aware of these conditions from earlier claims. Reluctantly, Mr. S.P. complied, and his policy was updated in January 2024.
Despite this, his claim submission on January 9, 2024, resulted in a bureaucratic nightmare. Multiple claim IDs were generated, additional documents were requested in piecemeal fashion, and eventually, the claim was denied without any legitimate reason.
The Injustice Continues: Multiple Claim IDs and Baseless Rejections
From February to April 2024, Mr. S.P. faced relentless hurdles. His claim was rejected multiple times, citing reasons that were either incorrect or unrelated to his wife’s medical condition. Despite submitting all required documents and clarifications, ABHI continued to create new claim IDs, making the process increasingly convoluted. The insurer’s insistence on updating already known medical conditions as PED only added to the frustration.
In one instance, the claim was denied on the grounds of "non-disclosure" of Diabetes Mellitus and Hypertension, conditions that were, in fact, already known to ABHI. Requests for evidence of non-disclosure were met with silence, and complaints were closed without resolution.
A Complete Mess of Violations and Discrepancies
Throughout this ordeal, several violations and discrepancies by ABHI became glaringly evident:
- Allegations of Non-Disclosure Without Proof: ABHI repeatedly accused Mr. S.P. of non-disclosure of pre-existing conditions without providing any substantial evidence. Despite the insurer’s prior knowledge of these conditions, these baseless allegations were used as a reason to reject valid claims. 🚫
- Multiple Claim ID Registrations: The process was further complicated by the registration of multiple claim IDs at different intervals. This not only caused unnecessary confusion but also reflected a lack of coordination within ABHI’s claims department. 🔄
- Failure to Provide Proposal Form and Detailed Terms and Conditions: From the outset, Mr. S.P. was not given a proposal form or the detailed terms and conditions of the policy, violating basic regulatory requirements and leaving him without the necessary information to make informed decisions. 📜
- Multiple Policy IDs and Client IDs: ABHI’s handling of the case was marred by the generation of multiple policy IDs and client IDs, which only added to the chaos and hindered the claims process. The lack of a streamlined process resulted in a complete mess, causing significant distress to the senior citizen. 🆔
- Mismanagement and Lack of Accountability: The entire situation highlighted a severe mismanagement of Mr. S.P.’s claims, with ABHI failing to provide consistent information or accountability at any stage of the process. ❌
Conclusion: A Call for Accountability
Mr. S.P.’s experience with ABHI reveals a disturbing pattern of regulatory violations, including generating multiple claim IDs, demanding unnecessary documentation, and making unfounded accusations of non-disclosure. These actions not only violate the IRDAI guidelines but also demonstrate a blatant disregard for the rights of policyholders, particularly senior citizens.
The actions of ABHI not only caused unnecessary distress but also deprived a senior citizen of his rightful claim. It is imperative for regulatory bodies to take strict action against such illegal practices and ensure that insurers are held accountable for their actions. Senior citizens, who are among the most vulnerable in our society, deserve fair treatment and respect from the institutions that are supposed to protect them.
The case of Mr. S.P. and Mrs. V.P. should serve as a wake-up call for all policyholders to be vigilant and for insurers to act with integrity and transparency. It is only through collective action that such unfair practices can be eradicated from the industry. 🌟🛡️
Disclaimer: This blog is based on the written complaint and evidence submitted by the complainant to the insurer. It is intended solely to present the facts and issues raised by the complainant regarding their experience with the insurer. All personal details of the complainant and other sensitive information have been made discreet to protect privacy. There is no intention to defame or malign any individual or organization mentioned herein. The insurer is committed to resolving grievances and improving their services. This blog aims to raise awareness about current insurance practices and highlight areas for potential improvement, not to discredit or disparage any party involved.
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