Hi, this is vijay kale.
I had taken a policy from star health and allied insurance (Referred to as star insurance in further body).
While taking the policy i had clearly mentioned that i smoke as well as consume alcohol occasionally. Copy of form as acquired by the insurance agent is attached below.
On 15th sept, 2018 there was a lot of pain in my abdomen and i was suffering from unusually high bp.
I met my doctor the very same day and i was suggested to get an endoscopy done.
Since endoscopy is not easily available nearby in panvel, i called up a few hospitals and decided to get my endoscopy done at zen multispeciality hospital, chembur.
On monday morning i reached the hospital and they immediately admitted me. One of the reasons that i chose this hospital to get treated as the cashless facility available there under a tie-up with star insurance.
Before admission, i had presented my insurance card to the tpa of that hospital and informed him that this is under the cashless scheme of star insurance.
To my surprise, the hospital asked me to deposit 20, 000 as a security deposit telling me that this will be refunded after the claim is settled.
My treatment started completely worry-free as i thought i am under the protection of my medi claim plan. After endoscopy, i was diagnosed with a disease called duodenitis.
When the doctors asked me did i drink, i made a full disclosure about when i last consumed alcohol.
I was admitted for a period of 2 days and on the day of discharge just a few hours before the billing i was informed that my claim by star insurance has been declined. The copy of claim decline by star insurance and the reasons are attached below.
The reasons for declining my claim as per the communication received reads as below.
"we note that the insured patient has been admitted with complications traceable to - duodinitis following alcohol consumption. Expenses for such treatment are not admissible in accordance with exclusion no.9 of the policy."
On contacting the insurance agent i got the point no 9 (Also attached below) and reads naturopathy treatment.
It is very clear from the attached screenshot that they have mentioned point no 9 which was supposed to be the point no 7. Which reads as intentional self injury and the use of intoxicating drugs.
Giving these baseless reasons they rejected my claim. A few points which i would like to highlight.
1. During taking this policy i had already informed them of my occasional drinking habits.
2. Duodenitis - can happen by bacterial infection as well and by taking an overdose of alcohol as well. And i had just consumed 2 units of alcohol. That too 48-72 hours before i faced the issue.
When i was taking the policy i had clearly mentioned that i consume alcohol and that too very occasionally and when the doctor asked me i made a complete disclosure about the same.
Star insurance did not even verify the actual reason and declined my claim.
According to me this a general fraud which insurance companies run and i seek to get justice out of this complaint.
Details of incidence and the resolution i seek areas below.
Date of admission - 17th and 18th september.
Customer id[protected]
Desired resolution - acceptance of claim and refund of complete treatment amount of rs. 20, 000
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