Admitted by the doctor, denied by the insurer
'The emergency doctor began treatment with IV and recommended hospitalisation citing potential symptoms of dengue and the risk of recurring fever,' Sumit said. She was admitted between 5 and 6 PM.
He called Star Health again. 'Their representative assured me: 'If she is admitted for more than 24 hours, your claim will be approved.''That's not what happened.Despite the doctor's advice and a hospital stay of over 48 hours, Star Health denied the claim repeatedly. Their reason: 'Hospitalisation was not medically necessary/does not warrant hospitalisation.''I followed medical advice. Isn't that what a responsible husband should do?' Sumit wrote. Over the next few days, he submitted not one but three letters from the treating doctor explaining why admission was required. Star Health rejected them all.'They kept saying, 'After careful consideration, we believe hospitalisation was not required.' But who are they to decide that over the doctor?' he told IndiaToday.in. 'They never explained it properly. Just copy-paste responses.'
Meanwhile, as the claim remained stuck, Sumit also flagged a billing error at the hospital and eventually negotiated the final bill down to Rs 41,000, paid out of pocket.The financial burden was one thing. The emotional cost was another. 'It's emotionally exhausting,' he said. 'You're worried about your wife, running around with documents, emailing, calling, begging.'He kept following up with Star Health, sending all the paperwork they asked for. The claim was rejected three times.Then he went public.On July 26, Sumit shared his full experience on LinkedIn. 'My issue is getting resolved only because the post went viral,' he said. 'What about the others?' His post gathered traction within hours, thousands of views, comments from others with similar experiences, and a flurry of attention.advertisementThe very next morning, Star Health called him. 'They apologised and said they're approving my claim now. Not the full Rs 41,000, but Rs 36,000, at least something.'He didn't submit any new documents. The only thing that changed was public scrutiny.Sumit's final line on LinkedIn summed it up: 'We pay premiums for peace of mind, not for mental harassment.'In a statement to IndiaToday.in, Star Health Insurance said, "At Star Health Insurance, all claims are reviewed by qualified medical professionals who assess the necessity of hospitalisation based on clinical evidence and established treatment protocols.""In this particular case, the initial documents submitted did not sufficiently establish the medical necessity for hospitalisation. Additionally, there were discrepancies in the hospital bill, including unusually high quantities of medication, which required further clarification," Star Health said. The insurer maintained that its team was in active communication with Sumit throughout the process and provided support for a 'seamless claim experience.'"The post-discharge and submission of a revised bill as well as the detailed indoor case papers, the claim was re-evaluated, found valid, and the reimbursement has been successfully processed," it added.advertisement(This report is part of our weekly series highlighting cases where individuals have faced undue health insurance claim rejections. If you've experienced something similar and would like to share your story, write to koustav.das@aajtak.com.)- Ends
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