[Resolved]  Star Health / Mediclaim Policy — Non payment of cashless amount for the hospital expenses by Star Health & Allied Insu

Address: Delhi

Sir, I must accept one of the biggest mistakes in my life was to rely on Star Health and buy their mediclaim policy for my parents.
Last week only (12th October 2011), I had to take my father to the hospital and he had to be hospitalized. Unfortunately just after two days, my mother also fell ill and had to be hospitalized. My father was diagnosed with “Arbo Viral Flu” and mother was diagnosed with “Chickengunia & Typhoid”. We intimated their claim department for the same and got the claim number. The same day of their admission in the hospital, the survey by Star Health’s doctor was done. We got the initial approval of INR 8K for each of them. Everything was fine till this point of time.
The problem came when the final bill by the hospital was generated and sent to their office for the approval (total bill of INR 19153 for my father & INR 31802 for my mother). In case of my father, they said that they cannot go beyond the cashless approval of 13174 for this particular disease. While in my mother’s case, these people told me that when all the reports are fine then why she was kept in the hospital for six days, so they cannot pass the cashless claim of further amount.
Here I would like to contradict some of their points:
1. Where in the policy, it is written that for certain diseases the cashless amount cannot go beyond (considering the sum assured)
2. If they do not provide 100% cashless benefits then why do they claim for the same during the selling of the policy? If this is well communicated to us then we can consider buying other companies’ policy rather than theirs. This way there is no sense in buying the insurance policy of Star Health
3. Unless and until the tests are conducted, how would you diagnose the disease? Even if the reports come out to be fine it does not mean that there was no requirement to admit the patient. Assuming the doctor must have felt the need to do the same
4. Even if they feel that the hospital prolonged the stay or conducted some non required tests then they must delist this hospital from their panel. As we went to this hospital which is a part of their panel only.
5. If they conduct the survey to check if the patient is genuinely admitted in the hospital then it’s also their responsibility to check if the hospital is conducting the required checkups during the course of the patients stay or not. So they should make much more visits. In this case we gave our go ahead to the hospital only after getting the initial approval from them (which they denied later)
6. Being laymen, how can I understand if the hospital even in their panel is doing the genuine checkups or not.
I want the reimbursement of the balance amount as getting a cashless claim is not my right but getting a reimbursement is my right. If this does not happen then I can go to other forums as well such as consumer court, IRDA, state department of insurance, etc.
Details of my parent’s policy and claim is as follows:
Father’s name: Pawan Kumar Gupta
Policy number:[protected]
Claim number: 0080023

Mother’s name: Sunita Gupta
Policy number:[protected]
Claim number: 0080594