Hospitalisation claim rejection and policy cancellation from Health Insurance Co

10 months ago

My mother has Senior Citizen Health Insurance policy on Feb, 2016 and her hospitalization claim for Respiratory ASTMA disease and Hypertension was rejected from the Health Ins co. stating that she had Heart disease as per 1999 discharge card. The Respiratory disease ASTMA, Hypertension and Acute Calculus Gall bladder stone was already declared 2016. While purchasing the policy Star health insurance representative told us to declare the existing disease of my mother during the near proximity purchasing the insurance. My Mother had only Respiratory disease, ASTHMA, and hypertension during the near proximity in 2016 and she didn't had heart disease and these existing mentioned in the latest hospital discharge card in 2006, 2019, 2022 and 2023 that my mother is suffering from Respiratory disease and Hypertension since 20 years. My mother has been renewing the policy since 2016 and till date and it was my mother's first claim. In the current health renewed policy document and IRDA pre-existing disease guidelines it is mentioned that " As part of Guidelines on Standardization IRDAI has already defined Pre-Existing Disease. A Pre-existing disease is defined as under (reproduced verbatim).
Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and/or were diagnosed, and / or for which medical advice/treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter."
My mother didn't have Heart Disease within the 4 years of the Health Insurance policy in 2016 and from 2000 till date, She has been suffering from Respiratory Disease ASTMA and Hypertension since 20 years and it is mentioned in the discharge summary from 2008, 2016, 2022, 2023 by our family hospital doctor.
Still they have rejected the claim and cancelled the policy
We have raised complaint to IRDA and we are not satisfied and didn't accept the Claim Rejection reply from Health Insurance
We have also raise complaint against Heallth Insurance to INSURANCE OMBUDSMAN at Santacruz on Jan, 2023 and waiting for the hearing
My mother was again admitted to the hospital for FEMUR bone fracture and the Health insurance didn't raise the claim initiation request for claim reimbursement and we submitted the 2nd hospitalisation documnets, bills to Health insurance company and they didn't reply for it
We also tried to RENEW the policy before expiry on Feb, 2023 and still they allow to proceed with the policy renewable. We have informed to Star Health Insurance about these and still they didn't resolved the issue.
On May 12, 2023 they send us last year policy and on the back of the policy they have hand written that my mother is cancelled with DD amount of about 34,000 (premium amount) DATED 31/03/2023. They didn't sent the Policy Cancellation official letter. The sender name was not mentioned in the courier.
We replied and email to Health Insurance company that WE DON"T ACCEPT MY MOTHER POLICY CANCELLAION and would escalate to INSURANC OMBUDSMAN and to legal department
So we again submitted complaint against to INSURANCE OMBUDSMAN at Santacruz office on May, 2023 subject as below
SUBJECT 1) Complaints against Star health insurance:
a) Complaint No. 2 for not reimbursing and raising the claim request for hospitalisation claim of my mother Mrs. Kalavati G Chandrani Star Health Senior Citizen red carpet Policy No. P/700016/01/2022/030290 even after submitting document at Star Health Insurance office. My mother was diagnosed and operated for LEFT FEMUR INTER TROCHANTERIC FRACTURE, HYPERTENSION and BROCHIAL ASTMA on 13th Feb,2023

b) Complaint No. 3 for not allowing to RENEW my mother Star Health Senior Citizen Red Carpet health insurance policy that got expired on 24 Feb, 2023 online. Many follow up mails and letter were sent and receive no proper response from them

c) Expedite the complaint No. 1 - MUM-H-044-2223–2853 Mr. NARAYAN. G. CHANDRANI Vs. STAR HEALTH & ALLIED INSC.CO. Ltd. and request to MERGE the Complaints No. 1, 2 and 3 into One complaint for the hearing
So can we file case against health insurance company in CONSUMER COURT or wait for INSURANCE OMBUDSMANT reply