Star Health And Allied Insurance — group health insurance - certain grievances in claims

Address: Madurai, Tamil Nadu

To
Star health & allied insurance co. Ltd., (Grievance department)
No.1, new tank street,
Valluvar kottam high road,
Nungambakkam,
Chennai - 600034.

Sir,
Sub: group health insurance - certain grievances in claims – regarding.
—
Ceoa schools are running educational institutions at madurai and kariapatti. We had tied up with star health insurance and extended health insurance to all our employees. For this, as a trial, we entered an agreement with star health on 31.03.2017 for 264 employees and their families (Policy no. P/121311/01/2017/006905).

2. Now, we have decided to extend the health cover to all our employees and their families in the year 2018 also. We strongly believed that the service provided by star health would be satisfactory and would serve to the needs of our employees. But to our surprise it is noticed that the services provided by the company is very poor. The company finds ways and means to curtail the claims or even to reject the claims. If the star health is very serious in continuing the business with our institutions, the following grievances should be addressed immediately.
1. The identity cards for few of our staff have not yet been issued. They may be issued at the earliest.
2. Case no.1: in respect of policy no. P/121311/01/2017/006905
Intimation no. Cli/2018/121311/0046623
Patient name: v. Krishnamoorthy, the patient was admitted at meenakshi mission hospital on 01.05.2017 with spondylodiscitis of c5 and c6 vertebrae with prevertebral abscess collection. Ortho opinion had been obtained and c4c5, c6c7 intervertebral disc removed and bone graft was placed. The claim was rejected by the company on the following grounds.
Findings as on 04/05/2017:
I. As per submitted documents, patient is a k/c/o diab, nephropathy, ckd on hd.
Ii. Estimated amount is too high.
Iii. As partial payment for abcess treatment alone is not possible, cashless is denied.
Iv. Reimbursement may be done based on merits.
Findings as on 05/08/2017:
I. It is observed from the hospital discharge summary that the insured person had under gone treatment related to intervertebral cervical diseases and musculo skeletal disease during the first year of the policy.
Ii. As per exclusion no.3 of the policy the expenses incurred during the first two years of the policy for the above mentioned ailment is not admissible.
Iii. It is a pre existing disease.
Iv. Since it is a pre-existing disease, as per exclusion no.4 of the policy, reimbursement can not be made till 48 months of continuous coverage.
From the above it is clear that the company wants to reject the claim by any means. The observations made above on two dates are entirely different. The cause of rejection by the company is baseless on following grounds.
I. The company had stated that the estimated amount is too high and hence partial payment for abcess treatment alone can not be done.

- the patient had under gone only abcess treatment and the estimated amount is rs.1, 78, 000/- which is well within the insured amount of rs.2 lakhs. Hence the objection is not sustainable.
Ii. Though cashless treatment facility was available, the company directed to go for reimbursement claim with an intention to deny the claim.
V. The company had stated that it is observed from the hospital discharge summary that the insured person had under gone treatment related to intervertebral cervical diseases and musculo skeletal disease during the first year of the policy. As per exclusion no.3 of the policy the expenses incurred during the first two years of the policy for the above mentioned ailment is not admissible.

- as per 3 (A) and 3e of the policy schedule, the exclusions are, “ ….. Prolapse of intervertebral disc……..” and “…….. Degenerative disc and vertebral diseases including replacement of bones and joints and degenerative diseases of the musculo-skeletal system”.
But as per the discharge summary of the hospital, the patient had infected spondylodiscitis with abscess collection which was removed. Hence it is no way connected with the diseases covered under the exclusion clauses of the policy schedule.
- since it is a pre-existing disease, as per exclusion no.4 of the policy, reimbursement can not be made till 48 months of continuous coverage.
From the hospital records and discharge summory it is clear that the patient is a known case of acute ckd. But the treatment undergone is only for “infected spondylodiscitis with abscess collection”. Hence the patient had not undergone treatment for the pre existing disease ie., ckd. Hence exclusion no.4 is not applicable in this case.
From the above it is evident that the claim is genuine and well covered within the ambits of the policy.
Case no.2: policy no. P/121311/01/2017/006905
Intimation no. Cli/2018/121311/0187425
Patient name: s. Gopal

The total expenditure incurred by the patient was rs.24, 109/- and the reimbursement was curtailed to rs.14, 969/- disallowing rs.9, 140/- stating the reason that “exceeded authourised amount”.
The patient had dengue fever and been hospitalized for four days. Rs.24, 109/- for treatment for dengue for four days hospitalization appears genuine and had been paid by the patient. The term “authourised amount” does not appear in the policy contract and it is a new invention by the company to curtail the claim. Only 60% of the claim is reimbursed. Since claim is genuine, and the entire amount has been paid by the patient to the hospital, the balance amount of rs.9140 may be reimbursed immediately.

Case no.3: policy no. P/121311/01/2017/006905
Intimation no. Cli/2018/121311/0082992
Patient name: t. Beulah

The patient had taken treatment in ganesh nursing home, madurai from 22.05.2017 to 28.05.2017. The company had requested for certain documents viz., original final bills, self declaration etc., they had already been submitted to the company through the branch manager. Surprisingly, we had received a letter from the star health that the claim is rejected.

Since the required documents have been produced, the reimbursement may be done at the earliest.

3. We had taken out health insurance policy to our employees through star health as a welfare measure and we have proposed to expand the coverage to all our employees numbering about 1000. Now, whether we have to continue with star health, or switch over to other better health insurance company for a better service lies in your hand only.

4. Hence, if the star health is interested in continuation of the tie up with ceoa groups, i wish the company should resolve the above grievances in the interest of our institution and also in the interest of star health by reimbursing the entire amount paid by the aforesaid patients.