HDFC Ergo General Insurance — Arbitrarily denying my claim

Address:

mumbai

Ref: optima policy restore no. Aa[protected]

I am insured since 2012 and i have ported to optima restore of apollo munich health insurance since 2018 which is now hdfc ergo. I have been using this insurance for 2 years now and i have never claimed any reimbursement till date.

I am now going to explain my issue by listing everything date wise for clarity purposes and all the documents referred to are already submitted to grievance team and cgo team and not being attached here due to privacy issues.

I was admitted on 14.02.2020 in delhi during an official visit at indraprastha apollo hospital by doctor s l broor under patient id apd1.[protected]. (Refer discharge summary for details) and i had given my optima policy restore no. Aa[protected] to the tpa desk. It is pertinent to note that i went to indraprastha apollo hospital particularly as i was insured with apollo munich.

They did the ct scan on 15.02.2020 in the morning and diagnosed me for crohn's disease but were not 100% sure as they thought it might be tuberculosis.

On 15.02.2020, a doctor from the s l broor team filled up the cashless request form and gave it to the insurance tpa desk in which he mentioned that i had crohn's disease.

On 15.02.2020: i received a letter from the insurer asking for duration of crohn's disease, etc as they were unaware that i was just recently diagnosed (Refer pdf named doctor statement page no.1)

They did various other scans like colonoscopy, x ray, fibroscan, etc from 15th to 18th to diagnose me and confirmed it as crohn's disease. However the doctor asked to meet him with a pathology report of colonoscopy later in opd for confirmation of crohn's disease. It is well known to the medical world that tuberculosis and crohn's disease are very similar and often need lots of tests and accuracy to exactly determine which disease the patient exactly has. (Refer discharge summary)

On 18.02.2020: the doctor replied to the letter dated 15.02.2020 sent by my insurer and by mistake he has written that i am having crohn's disease since 2015 (Refer pdf named doctor statement page 2). I had not seen the letter as i was in my hospital bed and my attender who was from delhi did not know to read english.

Therefore on 18.02.2020, my cashless request was denied. So i paid all the hospital bills of rs.1.6 lakhs and got discharged.
On 05.03.2020: did follow up visit with dr. S l broor in his opd with a pathology report as instructed. He confirmed that it is crohn's disease but he advised me to meet again after 1 month during which he will get 2nd opinion from another doctor just to be on the safer side.

05.03.2020: dr. S l broor based on my request gave a doctor certificate in which he clearly writes that "he had given an earlier letter dated 18.02.2020 mentioning that i have had crohn's disease since 2015 by mistake. He clarifies that i was admitted on 14.02.2020 and that i was diagnosed with crohn's disease thereafter. (Refer pdf named doctor statement page 3).

You should understand that i would not have not done ct scan, colonoscopy, fibroscan, etc if i already knew that i have crohn's disease.

Now in spite of me giving the doctor certificate dated 05.03.2020 which clearly states that i was diagnosed for crohn's disease after my admission on 14.02.2020, the insurance customer care team and the escalation level 1 i. E. [protected]@hdfcergohealth.com and escalation level 2 i. E. [protected]@hdfcergo.com are demanding me to provide an"affidavit from treating doctor mentioning 1st diagnosis date of the condition crohn’s disease". (Please refer to the pdf named diagnosis date).

The doctor denied giving me an affidavit and stated that he has not been asked by anyone in his 40 years of experience to give an affidavit and that doctors as professionals can only give in writing on their letter head duly signed and sealed which he has already given me. (Refer doctor certificate). Further, you fail to understand that i am in bangalore and being a resident of bangalore, this doctor and the hospital is in delhi.in spite of this i have been running from pillar to post and have requested their medical records team, doctor and also their dms team at the hospital to assist me but i have got no help from anyone.

So ultimately, in spite of me being insured since 6 years and 2 years with apollo munich - the insurer, just because i have been diagnosed now with a new disease, you are not willing to accept that i have been diagnosed with a new disease and therefore will not process any claims i make with respect to this new disease meaning that me being a insured person is meaningless and useless.

(I will provide all the documents referred to here i[censored] send me a email or share your email with me)