How I used Bima Lokpal to contest my health insurance claim rejection and won

Last Updated on August 7, 2024 at 10:12 am

In this article, Sunil explains how he contested a health insurance claim rejection with the Insurance Ombudsman (Bima Lokpal portal) and won. Sunil prefers that the health insurance company not be named in the article (the editorial team at Freefincal is also unaware of this). The procedure followed matters more to the reader, as it would be helpful regardless of who that insurer is.

We all want to live a healthy life without any major diseases or illnesses with present awareness; we take care of our health with proper exercise and a healthy diet and consult our doctors. However, we may still face situations in which we end up in a Hospital ( for reasons beyond our control ) & for such a situation, we prepare ourselves by buying adequate health insurance, Hoping that Insurance will help us when we need it!! But that’s not the reality.

This is what exactly happened to us & sharing our story can help many others to be well-prepared & well educated & knowledgeable.

I have had a family floater health insurance for the last 15+ years. Recently, my wife was hospitalized & since she had Employer insurance ( with limited benefits ), we used it as the first preference for cashless settlement. This insurance paid 65% of the bill amount, which was as per the Terms & conditions.

After discharge, I raised a claim with my insurance for the balance of 35% ( which fulfils my insurance policy criteria ) & submitted all documents, bills, and reports needed for processing.

To my surprise, my insurance company informed me that only 20% of the claimed amount qualifies. Since this was utter nonsense & unacceptable, I raised the Grievance with the company’s Insurance Grievance officer & unfortunately, they also didn’t respond properly & increased the amount only a little bit.

This was frustrating since there was no one to call (all calls went to untrained Call centres, and there was no support from any Grievance Person). It was very disappointing after being a customer for 15 years & the first claim!!

Since I was aware of Bima Lokpal (Insurance Ombudsman Portal, links below), I raised an Online grievance (a straightforward process!) to get Justice & Dues.

I documented each & every record ( Right from admission to discharge, all emails I sent to the Insurance company ) and drafted a detailed day-wise sequence of events. Within a couple of weeks, Bima Lokpal sent a notice to the Insurance company & insurance company started contacting me for details. They took all the details from me & concluded my claim was correct & agreed to pay me the claim amount I raised !!!

This leads to key Learnings & lessons I would like to share

First, be prepared to face a situation where you may not get your Due claim even if you have high Insurance coverage, as companies might find all ways to see how they can deny/defer your claim ( All may not do, but there are enough terrible experiences around to be careful )

1. Know your Policy’s basic Terms & conditions well in advance, such as Room rent coverage, Co-pay clause, waiting periods, Pre-existing disease waiting, inclusion & exclusion of charges, etc. Study well before buying the policy, even if you have held the policy for a long time

2. Do check your hospital bill details as well as check if the insurance company has rejected any specific cost for an incorrect reason

3. Keep your Documentation perfect. Store all soft copies / hard copies of each & every consultation report, bill, lab report, etc., by the Date. Those will be very useful in future

4 If not satisfied with the settlement, write to the Insurance company Grievance, with a 50% chance they may help for better resolution.

5. If still unsatisfied, go to BimaLokpal….. The entire process of raising the claim till Settlement is ONLINE; you don’t need to step out of your home !! Works efficiently & easily

6. Never Give up….in the present online era, by writing a Well-drafted email to a concerned person ( and sometimes with a couple of follow-ups), you will get help & resolution.

7. If your case is genuine, don’t give up. Take help from someone in family/friends / financial advisor if you are not well conversant with online / emails, but getting our Dues is our right as customers & we should exercise time to time

Also, Bima Lokpal can be contacted for insurance complaints ( Health, Motor, Life ); you can find more information about them online.

To raise a complaint, use the following links.

https://cioins.co.in/Complaint
https://bimabharosa.irdai.gov.in/RegComplaint/RegisterComplaint

Regards
Sunil  A Common Man who fights for due Rights!)

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