Navigating Health Insurance Challenges: Mrs. Shah’s Story

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Many health insurance companies followed different claim approval processes during the pandemic since nobody knew something like this could happen. Guidelines were unclear, so policyholders faced various problems leading to claim rejection, claim delays, and claim short-settled. In 2021, Mrs. Suvarna S Shah was hospitalized when she contracted the coronavirus. While everyone prayed for her quick recovery, the hospital made a huge bill. However, the family was not worried about the bill since they had a health insurance plan.

Navigating Health Insurance Challenges

The family received a total bill of INR 1,57,720 for covered medical treatment. However, when they submitted a claim to their insurance provider, the claim was short-settled per the terms and conditions outlined in their policy. For example, the policy may have specified certain limitations or exclusions, such as a cap on the amount covered for a particular treatment or a requirement for pre-authorization. While the family may have been surprised or disappointed by the short settlement, it’s important to carefully review the terms and conditions of any insurance policy to understand what is and is not covered. The family did not like the outcome and asked the insurer to reassess the case. After the initial short settlement, the insurance company re-calculated the claim and paid the customer an additional amount of 5500. Despite this, the family was still not satisfied with the outcome. 

Insurance Samadhan

So, when the family contacted Insurance Samadhan, our experts accepted the case to ensure that the Shah family got the remaining amount. They may have felt that the insurance policy needed to be more transparent or that they needed to be adequately informed about the limitations or exclusions. We analyzed the case and put it in the ombudsman’s office to ensure the family got what they deserved. 

The ombudsman office stated that the government of Gujarat had issued guidelines that were required to be fulfilled by hospitals providing COVID-19 treatment. These guidelines mandated that hospitals charge a certain rate for COVID-19 treatment and specified the services that must be provided to patients. It was determined that the hospital in question had followed these guidelines and had not overcharged the patient. Therefore, the ombudsman’s office directed the insurance company to pay the remaining amount of INR 22,400, as the claim was found to be legitimate and the hospital had followed the required guidelines. This highlights the importance of clear and consistent regulations to ensure that patients receive fair and affordable treatment and that insurance companies honor legitimate claims.

Insurance Samadhan keeps fighting for justice by providing comprehensive support to policyholders in their quest for fair insurance settlements. Our team of experts helps consumers understand their policies, identify coverage gaps and negotiate with insurance companies on their behalf.

Insurance Samadhan

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Shikhar Vashisht

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