Can I challenge my insurance claim rejection due to emergencies?
Dear Sir/Madam, I am seeking your legal advice regarding my health insurance claim, which has recently been rejected by my insurance company. My mother faced a critical health condition, and due to the severity of her condition and the lack of nearby medical facilities, I sought treatment at a smaller hospital close to my residence. The nearest larger hospital was over 150 kilometres away, and travelling such a distance under the circumstances was not feasible. The insurance company rejected my claim on the grounds that the hospital where I received treatment does not meet the size requirements stipulated in the policy terms and conditions. I had no alternative due to the emergency situation. Is the insurance company justified in rejecting my claim based on the hospital size criteria, despite the emergency circumstances and lack of nearby alternatives? Do I have grounds to legally challenge the insurance company's decision, and if so, what would the process entail? Thank you for your assistance.
ou must be able to challenge the decision under the circumstances of rejection of your health insurance claim. Hospital size is no bar in emergency situations; besides, nothing can be more justified than going to the nearest facility when no other alternative exists. You may also lodge a complaint with the insurance ombudsman and appeal to the consumer court on these grounds. Keep record of all communications. Always retain evidence for your case since this gives one a stronger stance in any case in court.
First, review your health insurance policy, focusing on hospitalization clauses and criteria for eligible hospitals. While insurers may have specific stipulations, emergency situations can create exceptions. You may have grounds to challenge the rejection based on the urgency of your situation and lack of nearby hospitals. Document the emergency details, including medical records and communications about available facilities. Start by filing a formal complaint with the insurance company’s grievance redressal department. If their response is unsatisfactory, you can consider escalating the matter to the Insurance Ombudsman or the Insurance Regulatory and Development Authority of India (IRDAI). Consider consulting a lawyer if unresolved.
Sir, firstly you should examine the terms and conditions of your health insurance policy especially related to covered facilities and emergency care, then you may send an appeal letter outlining the mother's critical condition and lack of nearby facilities. It is advised to consult an expert lawyer who will assist you in understanding your rights. For further legal assistance contact us on our helpline number.
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