Aegon Religare — non justified refusal of genuine medical claim by religare health insurance-

Address:

Gurgaon, Haryana, 122001

My self being a critical care anaesthetist staying bangalore was using religare health insurance policy from last four year and added my wife (Currently in gurgaon) also in same policy last year and never had any requirement or need of any claim until this month.
Last week[protected] my wife who is also md medicine got high grade fever with headache weakness and other associated symptoms. Being medico on symptom basis oral medications were started for fever and all and next day got investigation also done form medanta hospital to further evaluate.in view suspected fever - investigation for dengue, malaria, typhoid were done as these were quite prevalent during this season but all serology initial reports came negative except low total leucocytes of 2.5 thousand /ccmm count and platelet were also trending toward lower side.
In the mean time fever, weakness headache other symptoms were still persisting. On sunday[protected] night her weakness got worsened along with headache and sweating and was not able to eat or drink properly because of her current condition.
So she was referred on 17-09-17 night around 10:00 pm to medanta emergency medicine and was evaluated by the medicine team and she was advised admission on suspected acute febrile illness –with suspected swine flu and extreme weakness and headache. She was advised for intravenous fluids and intravenous medication she was not able to take feed orally in view of her poor health condition.
In the mean time pre-authorisation form for religare health insurance was filled as per requirement.
Investigation for swine flu was send along with other investigations. Swine flu serology report was negative but total leucocytes counts were still lower than the normal suspecting acute viral illness. Patient was kept on iv fluids and medication until she condition become better.
Explanation for admission as needed by religare insurance team was provided by the treating doctor in written explaining the need for intravenous fluid and iv medication requirement and need for further evaluation 18 th of september 17 which could not be done on opd (Out patient basis) basis.
As her condition improved she was planned for discharge on 20-09-17 by the treating doctor.
But during discharge religare health insurance claim team denied claim for hospital bill giving unjustified reason as mentioned below:
• admission not justified for evaluation purpose it could be done on the opd basis
• admission not justified
Tried calling the religare health insurance customer care that made wait for 20-0 mins online, every time i had explain the full story to them and wanted the claim team to justify the refusal of my claim. But to my shock they were not ready to provide the justification and keep on repeating the reason that patient could be managed on opd basis.
I wanted to know on what basis religare team claming that patient could be managed on opd basis when patient in extreme weakness could not eat or drink, then how could patient take oral medication when patient required intravenous medication and fluids to support.
How can religare team can explain that swine flu suspected patient can be treated on opd basis who needed isolation in hospital. Swine flu was ruled out only after getting admission only after testing for serology keeping patient isolated.
According to religare they want to create the epidemic of swine flu as per their policy by keeping suspected patient un-isolated on opd basis that is against medical treatment.
Since i have paid for the policy for last 4 year and being a medico, i got all the right to know the justification for refusal of my claim and right to know how could patient have my patient be treated on opd basis as per the religare claim team.
Since i was refused for any justification for refusal for claim by religare claim team, sending this email for justifiction for the same from religare greviance team and my cliam amount which i had to pay and problems faced due to inappropriate policy toward the consumers problems.

Member id 54504476
Policy number 10041280
Al no :[protected]