“Hospitalisation was ‘unnecessary,’ they said”: The insurance dispute that went to the Ombudsman

In uncertain times, insurance is expected to act as a financial buffer, easing the burden of sudden and unexpected crises. Its value lies in the assurance that a medical emergency will not automatically become a financial one.Health insurance is meant to be a quiet safety net, paid for annually, stored digitally, and largely forgotten. It stays that way until the day it is needed. And when that day arrives, you assume the system will do what it promises. Well, until it turns out otherwise. Early last year, one of my friends, who was living away from home, fell ill with a fever. As usual, she brushed it off, took those usual medicines, and thought things would be ok. But, then the fever refused to break. What initially started off as something manageable, soon turned stubborn and alarming. She then went to see a doctor, and went for a routine round of tests. Medicines were prescribed, dosages increased, and days passed. Unfortunately, nothing worked. Since she was staying away from home, and was alone in the city, she decided to go home to be with her family. She took a flight in poor health, and hoped that returning home might help her. But then had to be hospitalised as her health further deteriorated. Doctors ran tests, and diagnosed typhoid. She stayed there under inpatient care, was monitored, treated, and eventually discharged. The medical bill she received was around INR 80,000. She thought it wouldn't be a big deal as she had insurance, and would claim the money afterwards. Well, things didn’t turn out that easy as it seemed. She submitted all the original documents, physical records were couriered. Verifications followed, and weeks passed. When she didn’t get any response, she started sending emails. Those too went unanswered. Then, after some months, maybe, she received a message with an accusation. Of course, her claim was denied. The reason cited for claim rejection was ‘misrepresentation’ and ‘fraud.’ She tried getting in touch with the insurance officials, then appealed through the company’s grievance redressal mechanism. She explained it clearly that she had sought treatment elsewhere because she needed her family support during that time. This time, they asked why she took treatment outside the city where the policy was issued? No clause was clearly explained, and she faced yet another rejection. She then escalated the case to the regulator through the government’s grievance platform. This time, the justification changed again. Now, the insurer claimed that the hospitalisation was unnecessary, that it was merely for diagnostic and evaluation purposes.It then became clear to her that nothing was going in her favour, and the system just wants her to rest her case. After months, and after emails after emails, when the usual route failed to bring relief, she approached the Insurance Ombudsman, and informed the insurance company about the same. This is when things suddenly started to move at a faster pace. Nearly a year after falling ill, the money finally came through. Sometimes, a fight stops being about money. Sometimes, it becomes more about fighting the system, and against those who want to twist the system for their benefit. As they say, one ordinary person can also bring a change if one has the will to do so.Disclaimer: This story is based on a real incident. The name of the individual involved has not been revealed, and identifying details have been withheld to protect privacy.