The Great Indian Health Insurance Story

P buys Hospital Daily Cash Cover (standalone) from Insurer A and a hospitalisation cover from Insurer B. P is hospitalised for an infection. Insurer B gives cashless approval for the hospitalisation claim. P also files claim with Insurer A for Hospital Daily Cash. Insurer A denies the fixed benefit claim on the ground of “discrepancies in internal case papers and purchase invoice of medicines against the quantity dispensed”.

Q buys a Hospitalisation cover Policy with an Add-On cover for Hospital Daily Cash from Insurer A. Q meets with an accident. He is taken to a hospital for emergency treatment, which is not on the network of the insurer. No cashless facility is available. So, Q moves to a network hospital after two days. Q’s claim for re-imbursement of hospitalisation expenses at the non-network hospital are paid by the insurer, along with the Daily Cash claim for two days. Cashless facility is provided for Q’s hospitalisation at the network hospital. Q’s claim for Hospital Daily Cash is denied for the reason “discrepancy was noted w.r.t. room rent charges and it was inflated”. 

R buys Hospital Daily Cash Cover (standalone) from Insurer C and a hospitalisation cover from Insurer D. R is hospitalised for fever and gastro-enteritis. Insurer D gives cashless approval for the hospitalisation claim. R also files claim with Insurer C for Hospital Daily Cash. Insurer C denies the fixed benefit claim on the ground that the indoor case records are in “stereotyped manner”, written in single handwriting (this was referring to a single 2-page document) and the records amounted to “misrepresentation”.

S buys Hospital Daily Cash Cover (standalone) from Insurer E and a hospitalisation cover from Insurer A. S is hospitalised for an infection. Insurer A gives cashless approval for the hospitalisation claim. S also files claim with Insurer E for Hospital Daily Cash. Insurer E denies the fixed benefit claim on the ground that “indoor case records of the hospital are in stereotyped manner and in single handwriting (this also was one single 2-page document) which amounts to misrepresentation”.

T buys a Hospitalisation cover Policy with an Add-On cover for Hospital Daily Cash from Insurer A. T is hospitalised for an infection. Cashless facility is provided for T’s hospitalisation claim. T’s claim for Hospital Daily Cash is denied for the reason “multiple discrepancies were noted including made-up pharmacy bills” (the bills which were approved by the same insurer). 

U buys Hospital Daily Cash Cover (standalone) from Insurer A and a hospitalisation cover from Insurer B. U is hospitalised for an infection. Insurer B gives cashless approval for the hospitalisation claim. U also files claim with Insurer A for Hospital Daily Cash. Insurer A denied the fixed benefit claim on the ground of “multiple discrepancies were noted including made-up pharmacy bills”.

Do I see a pattern here? This is just a small list of claims that were referred to me in a span of 7 days. It appears that the dealing persons have been hired with a job description which requires them to repudiate claims irrespective of facts. Its almost as if there is a drop-down menu of reasons, one of which is randomly selected. None of these repudiations stands any chance in a court of law. And they know it! That’s why, sometimes they don’t even try to defend their actions. And yet they will continue to reject more such claims, secure in their belief that not everyone will take them to court. The business model is thriving!