My son had a apendix operation in Dec 2022 .The medi-claim company rejected the health claim with the reason that there are multiple discrepancies in the claimed expenses/submitted documents .
Each and every Document/ Bill was provided by us given by the hospital.The actual scanned copies of each bill was given as requested in the email chain communication with Medical insurance company.We raised the matter with the ombudus man of the company seeking the details of the discrepancies in the documents so that we can clear any mis-information and did not get any further explanation in response:
Below is the reason in the denial letter:
On Perusal of claim documents ,we found that Insured Parth
Ahuja admitted at Pushpanjali Medical Centre From
09/12/2022 to 12/12/2022 for management of Acute
appendicitis .After internal claim verification we have noted
multiple discrepancies in the claimed expenses/submitted
documents, hence we regret to inform you that your your claim
stands repudiated as per policy terms and conditions
The denial clause :
Please Refer Policy General Terms & Conditions_ Clause No:
10.9. Fraud If any claim made by the insured person, is in any
respect fraudulent, or if any false statement, or declaration is
made or used in support thereof, or if any fraudulent means or
devices are used by the insured person or anyone acting on
his/her behalf to obtain any benefit under this policy, all
benefits under this policy shall be forfeited. Any amount
already paid against claims which are found fraudulent later
under this policy shall be repaid by all person(s) named in the
policy schedule, who shall be jointly and severally liable for
such repayment. For the purpose of this clause, the expression
"fraud" means any of the following acts committed by the
Insured Person or by his agent, with intent to deceive the
insurer or to induce the insurer to issue an insurance Policy: -
a) The suggestion, as a fact of that which is not true and
which the Insured Person does not believe to be true; b) the
active concealment of a fact by the Insured Person having
knowledge or belief of the fact; c) any other act fitted to
deceive; and d) any such act or omission as the law specially
declares to be fraudulent The company shall not repudiate the
policy on the ground of fraud, if the insured person /
beneficiary can prove that the misstatement was true to the
best of his knowledge and there was no deliberate intention to
suppress the fact or that such mis-statement of or suppression
of material fact are within the knowledge of the insurer. Onus
of disproving is upon the policyholder, if alive, or beneficiaries.
Kindly advice on next steps for legal remedies.
Regards
Sachin kl Ahuja
Asked 2 years ago in Consumer Law
