- INSURANCE CLAIM REJECTED ^Open

ALWYN PETER RODRIGUES filed this complaint against Star Health Allied Insurance Company on Jul 03, 2023

Resolution Demanded:
Refund

CASE DETAILS

SUBJECT: CLAIM FOR ELBOW REVISION OPERATION EXPENSES REJECTED BY STAR HEALTH INSURANCE CO. AND THREAT BY COMPANY TO DISCONTINUE COVERAGE.

Background info: The operation was for removing a previously implanted metallic elbow joint because of pain due to infection. It was not a fresh operation but a revision operation and hence not connected to any disease.

*. Due to age related joint low mobility the original elbow joint was removed and a metallic joint was implanted in August ****.
*. The claim for this operation was covered by Oriental Insurance without any issue.
*. About ** days after operation I slipped in the bathroom and fell. The fall resulted in the unhealed wound opening. Though the heavy bleeding was somehow stopped some infection make have taken root.
*. The doctor who had done the operation started IV antibiotic injections at home followed by oral antibiotics. This continued for a few months but the wound did not close. Laser treatment was also tried. Eventually the wound closed but pain used to develop sometimes. Unfortunately Covid restrictions started and doctor did not agree for re operation. Antibiotics and pain killers helped. Since pain was bearable I continued with the same. Corrective surgery for Elbow replacement is rare in India. We searched and visited many doctors but their advice was not encouraging.
*. Ultimately we found Dr. Gautam Tawari in Apollo Hospital, Belapur, Mumbai. He did some tests and operation was scheduled for January ****.
*. A pre approval intimation was done by the hospital but Star Health did not respond. Even after many follow ups by hospital there was no intimation either to me or to hospital about approval. We decided to go ahead and claim after the operation.
*. After the operation emails were sent by me to enquire about the claim but there was no reply.
*. A letter was sent by us intimating initiation of legal proceedings if claim was not settled.
*. On about ** April **** a letter from Star Health dt. **rd March was received which said claim was rejected for non disclosure of pre existing disease and also they would stop coverage of policy.
**. A letter was sent by us refuting the allegation. I have never been diagnosed for Osteomyelitis or been under treatment for the same. Also the allegation was that I had the disease in **** but after this time claim for elbow implant was passed by Oriental Insurance without any issue. Also it is obvious that the letter was drafted and signed by a non-medical person as the disease mentioned was wrongly spelt.
**. Star did not address the points in my letter but sent another letter dt. *th May **** with the same contents but different implementation date.

The contention by Star is probably based on a speculative covering letter of the doctor who carried out CT scan. CT scan was done at a private clinic and the diagnosis of the doctor is not based on any medical history or previous scans. It was just speculative. Doctor Gautam’s pre operation notes, as well as a certificate given later clearly states that the operation was not necessitated because of disease but physical wound leading to local infection. If it was a disease it would have affected many other parts of the body and would show up in blood and other tests.
The rejection of claim and the threat to discontinue coverage is obviously not valid and is intended to harass a senior citizen depriving him of legitimate reimbursement of required medical expenses.

The case is to recover the claim amount and continue coverage of policy till next due date.

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