insurance company
Critical illness insurance provides financial protection in case of serious illnesses, but many times the insurance company rejects the claim. In such a situation, there is no need to panic. If your claim is rejected it does not mean that your claim is wrong. This decision can be reversed by adopting correct information and procedure.
First check the policy conditions
The first step to be taken in case your claim is rejected is to read your policy document carefully. Check whether your illness is included in the list of critical illnesses covered in the policy or not. Many policies cover diseases like bacterial meningitis, provided certain medical and testing conditions are met. In a similar case, a review of the policy revealed that the disease was included among the 32 covered diseases and the disease was clearly confirmed in the medical certificate.
Important role of medical evidence
If the policy terms and medical records match, the decision of the insurance company can be challenged. For this, it is very important to collect the documents of hospitalization, doctor’s certificate, investigation report and all the documents related to the severity of the disease.
Reach the grievance team of the insurance company
If the claim is rejected, the next step is to submit a written complaint to the grievance redressal team of the insurance company. In the complaint, clearly mention the relevant conditions of the policy and attach all the medical documents. In many cases, despite giving complete information, the insurance company sticks to its decision without giving any new reason. In such a situation, there is no need to be disappointed.
Can get relief from Ombudsman
If relief is not provided from the insurance company, a complaint can be filed with the Insurance Ombudsman. This process is completely free. The Ombudsman examines both the terms of the policy and the medical evidence. In one case, during the hearing, the policyholder produced hospital records and a certificate from the treating doctor, which stated that the patient had persistent neurological problems for more than six weeks. The insurance company could not present any concrete evidence against it.
decision in favor of client
After looking at all the documents, the Ombudsman ruled in favor of the policyholder and ordered the insurance company to pay the claim amount to the nominee.
What is learned?
This case teaches that it is very important to read the policy terms carefully, maintain complete medical documents and lodge a complaint at the right forum. Many times claims are approved simply because the facts and policy terms are in favor of the customer.