Aditya Birla Health Insurance — claim rejection without baseless allegations

Date: 16.04.2020
From
Mohan raj k
Mob-[protected]
B ii - 708, change quarters, indira nagar,
Kurinjipadi (Tk), neyveli-607801

To
Aditya birla health insurance co limited
Chennai

Sub: my genuine claim rejected by grievance cell regarding non approval of my insurance claim - regarding
Ref: by customer id 49545071 & policy no[protected]
My claim reference number[protected] – reg – mohanraj – rs. 319147.00
Dear sir,
I wish to inform you that the i had taken up activ assure - diamond policy for sum of rs.5, 00, 000 in the year november 2019. While taking the policy as a mandatory requirement as insisted by aditya birla, i have under gone all medical tests as per requirement of aditya birla on 17.11.2019 with your recognised panel of doctors during their check-up all the parameters were fine other than my diabetic condition. My diabetic condition has been disclosed in the policy document and the same has been loaded in my policy statement at page 3 of 7 it is to be noted that 20% extra premium has been loaded for diabetes mellitus
During my regular course of check-up for diabetes, it was found on 30.12.2019 that i need to be take medicines for hyper tension. Once again it is to be noted that at the time of taking the policy, i did not have hyper tension for which i had submitted my medical investigation report conducted by your authorised panel of doctor and medical investigation report dated 17.11.2019 has been submitted and the same has been observed and my policy premium has been calculated on considering my medical reports.
On, 20.02.2020 when i had a fracture initially i had been to neyveli general hospital for first aid and then for my further course of treatment i had undergone further course treatment at vasanth subramanian hospital (India) pvt ltd chennai, at the time of admission i had given my request for cash less treatment as per the provision available in the policy. However, at the time of discharge i am shocked to receive your message as follows.
"on scrutiny of the documents it has been observed that non-disclosure of hypertension and diabetes hence your claim is rejected and hence we are unable to approve the claim"

Since rejection of my claim is base-less i had again resubmitted all original bills along with documents through insurance form part b as per insurance provision. My reference number for the claim is[protected] the same has also been rejected due to the following reason
On scrutiny of the documents it has been observed that non-disclosure of hypertension hence your claim is rejected and hence we are unable to approve the claim"
Since i am not accepting the reason for rejection, i had taken up with the grievance cell about my rejection. Since the grievance cell has also rejected my claim without any valid remarks, i further escalating the same as per the provision of insurance
I want to clarify the following points
1. There are no non disclosures from my side at the time of taking my mediclaim policy. Iwish to clarify that i had submitted a detailed medical investigation report from your recognised panel of doctor (Dr. Jaya singh) vide their medical report dated 17.11.2019 which has indicates about diabetes only during the check-up it has been noted that the hyper tension in normal limits and the medical report has also indicates the same.
2. Based on my medical investigation reports only my policy value has been determined and policy has also mentioned about my diabetes mellitus in my policy statement page 3 of 7 that 20% extra has been loaded for diabetes mellitus.
3. When i am taking my policy i had already submitted my detailed medical investigation report dated 17.11.2019 which has been submitted to your office while taking my policy i further wish to inform you that i had done my medical check-up from your specified doctor of adithya birla only by your panel of doctor (Dr. Jaya singh) has also confirmed that i had been only diabetes mellitus at the time of taking the policy and the same has also been accepted and acknowledged by your office and my premium for my policy has been calculated accordingly on your study of my initial medical report
4. It is to be further noted that as per my medical investigation report submitted at the time of taking policy that there is no other pre-existing illness rather than diabetes.
5 during my course of treatment for diabetes mellitus on 30.12.2019 at dr. M. Sivasankar i had been advised to take medicines for hyper tension also which i want to clarify that it is only subsequent to taking the policy with you hence it cannot be taken as pre-existing illness.
.6. It is with deep regret i would like to record that since my cashless claim and insurance claim which has been submitted by part b was rejected without any valid genuine/legal reasons, i was under compulsion to make the complete payment from my own hard-earned money and presently i am without cash for further course of treatment.

7. I had submitted once again my claims for rs, 3, 19, 147.00 along with following documents
A) duly signed form a (Affixing thumb impression due to fracture)
B) duly signed form b from hospital
C) hospital discharge summary
D) hospital bills for rs.3, 19, 147.00 considering the above facts my insurance claim may please be considered and same be settled at early date.

8. I am also enclosing account statement details & copy of aadhar card for settlement of claim.
9. You are requested to review the same and accord approval on priority and pay the proceeds to my account since it is required for further course of treatment
` thanks & regards
K. Mohanraj

 

List of enclosures which has been submitted through part - b is as under:
A. Copy of insurance policy no.[protected], active assure – diamond dated 22.11.2019.
B. Medical check-up done by dr. Jayasingh m. D, 34923 done by aditya birla
C. Medical check-up report dated 30.12.2019 done by dr. M. Sivasankar m. D. D, m (Nephrology)
D. Thumb impressed form a due to fracture
E. Form b with submitted along with hospital discharge summary
F. Hospital bill for rs.3, 19, 147
G. Account details
H. Copy of aadhar card