Re: Health Insurance claim Rejection

[kpriyanka]

Policy Name

OG-25-1301-843300000069

Company Name

Bajaj Allianz general insurance company

Customer Care Number

1800-103-2529

Loss Amount

30000

Ratings

1.00 star(s)

Opposite Party Address

Bajaj Allianz general insurance company
3 floor Narain Building
shanajhaf road
hazratganj- Lucknow
226001

Dear sir,
This is to inform you that, I am a health policy holder of Bajaj Aliance Company with family floater plan ( policy Numbers- OG-25-1301-843300000069)
As on 27.03.2025 I got admitted at Ajanta Hospital due to food poisoning( loose motions) by 3:00 am.
I got admitted in emergency initially sample was taken for further diagnostic where I have been asked to deposit 10k initially as admission fees..after that i have shown my insurance card to further process and approvals.
I have been shifted to the semi private room same day where and after all the diagnostic reports next day I have been diagnosed with typhoid,diarrhoea and with the gall stone in ultrasound reports.
My all the reports and estimate of my treatment shared with the tpa as well as the Bajaj teams on the basis of that they have approved the request and grant to the initial Rs.15000/- approval to continue the treatment message received on 30/03/2025 at 8:59 pm( Dear Customer, We are in receipt of your cashless request at 08:52 PM vide claim ID 7580878 from AJANTA HOSPITAL AND IVF CENTRE PVT. LTD - LUCKNOW. Please quote the Claim ID in all your communications with us. If you have any concerns, please call 1800-103-2529. Caringly yours -Bajaj Allianz GIC )

After my recovery as per doctor I have to discharge from hospital on 01/04/2025 by 2:30 pm but due to carelessness of Bajaj I got the mail by 11:30 pm although that to after 50 follow up with agent and team and they have denied my approval with the excuse of the gall stone but as per the doctor and hospital i have been only treated for my diarrhoea and typhoid in the utra sound i have been only diagnosed with the non of the treatment was take for stone.The hospital not allowed me to totally harassed me for the payment I borrowed the money the do the pay of Rs.20504/- paid more to the hospital (10000+20504=Rs.30,504) on 02.04.2025 by 12:40 am

Sir, I have now I failed to understand that where the initial approval for 15000/- came from where there is also the all the reports was mention although the hospital himself separately mention on his personal letterhead that the treatment was only given for diarrhoea and typhoid only and no other investigation done by hospital part.
I have been going piller to post spoken 10 people in Bajaj but no response from them.
Iam written to with hope and humble request to please call up the matter and obliged.
All the documents are attached for your reference plz have a look and do the needful.

Priyanka Kanojia
Lucknow

 

[TeamMember]

Hello @kpriyanka

I'm sorry to hear about the rejection of your health insurance claim. Navigating such situations can be challenging, but there are structured steps you can follow to seek redressal in India. Here's a comprehensive guide to assist you:

---

Steps to Address a Rejected Health Insurance Claim​

1. Review the Rejection Reason
Carefully examine the insurer's communication to understand the specific reason for the claim denial. Common reasons include:

• Incorrect or incomplete documentation
• Claims filed during the policy's waiting period
• Exclusions specified in the policy
• Policy lapses or non-renewal

Understanding the exact cause will help in formulating an effective appeal.

2. File a Grievance with the Insurance Company
Initiate a formal complaint with your insurer's Grievance Redressal Officer (GRO). Provide all relevant details:

• Policy number
• Claim reference number
• Detailed explanation of the issue
• Supporting documents (medical reports, bills, correspondence)

The insurer is obligated to respond within 15 days.

3. File a Complaint with IRDAI:

• Online: Register your complaint through the Bima Bharosa System.
• Email: Send your complaint to complaints@irdai.gov.in.
• Phone: Call the toll-free numbers 155255 or 1800-4254-732 for assistance.

4. Issue a Legal Notice: A legal notice should be sent to Care Health Insurance demanding reimbursement, failing which you will initiate legal proceedings.
5. File a Complaint in Consumer Forum: You are advised to file a complaint before the District Consumer Disputes Redressal Commission, Nashik, seeking:

• Full claim amount with interest
• ₹1–2 lakhs as compensation for mental agony and harassment
• ₹10,000–25,000 as litigation cost

---

Legal Precedents Supporting Your Case​

Karnataka - Dakshina Kannada - Bajaj Allianz General Insurance Co. Ltd, V/S Veena S Rai

1. Bajaj Allianz General Insurance Co. Ltd, Represented by its Manager/ Authorized Signature, Maruti V/S 1. Veena S Rai, W/o Late Sanjeeva Rai M, Aged 47 years, - Consumer Court Case - 2024-12-20

Consumer Court Case against 1. Bajaj Allianz General Insurance Co. Ltd, Represented by its Manager/ Authorized Signature, Maruti V/S 1. Veena S Rai, W/o Late Sanjeeva Rai M, Aged 47 years, - Consumer Court Case against - 1. Bajaj Allianz General Insurance Co. Ltd, Represented by its Manager/...

www.consumercourt.in

Jammu and Kashmir - Srinagar - Bajaj Allianz General Insurance Co. Ltd & anr. V/S Ashiq Hussain Shah


Complainant, being in possession of residential house situated at Gundi Nowgam, Sumbal which he had constructed/renovated after availing financial assistance from opposite party (in short referred to as OP} no. 2, had insured the said house with OP No. 1 vide Standard Fire & Special Perils Policy bearing No. OG-15-1205-4001-00016416 for a sum assured of Rs 10.00 lacs. The OP1 agreed to indemnify the complainant subject to the terms and conditions laid down therein, the loss, if any, to the insured property (supra) due to insured perils during the period of twelve months w.e.f. 18.06.2014 to 17.06.2015. To his ill luck, the insured property (supra) during the validity of the insurance policy suffered extensive damage due to devastating floods of September, 2014 that hit the Valley of Kashmir. The property remained submerged in flood waters for a considerable period of time and resultantly the structure, load bearing walls, partition walls, flooring and other household goods got severely damaged and ultimately the building got collapsed necessitating its reconstruction. The occurrence came to be reported by the concerned Police Station. The complainant intimating the loss to OP1 claimed indemnification. This prompted appointment of Surveyor by OP1 who visited the spot, took photographs and demanded various documents from the complainant. The complainant rendered every sort of assistance by way of submitting all the necessary documents including copy of policy of insurance, claim form duly signed,estimate of loss, ownership proof etc. to the Surveyor who after receipt of the documents assured the complainant that the assessed amount would be paid to him within reasonable time. However, after lapse of more than four months, the complainant while visiting the office of OP1 came to know that OP1 has credited an amount of Rs 1,22,726/- into the account of the complainant being operated by him with OP2 which the complainant refused to accept and protested for being meager amount. Complainant not satisfied with the Indemnification amount served a legal notice upon OP1 and also requested them to provide a copy of survey report for examination and comparison with the actual loss suffered by him. It is being alleged that since the building remained submerged in flood waters for more than ten days, as such, the structure including partition walls, load bearing walls, floor etc developed deep cracks and need exhaustive repairs/renovations at estimated cost of Rs 8,13,839/-. Although, the OP1 was orally as well as through written representations requested to re-assess the loss with jeopardizing the rights of the complainant in the face of series of directions passed by the Hon'ble High Court in similarly situated matters, yet all these pleas fell to the deaf ears and nothing positive came to be done by them. It is being alleged that the OPs are hand in glove with each other which paved way to OP1 to credit a sum of Rs 1,22,726/- as indemnity amount into the account of the complainant without his knowledge and consent. Complainant maintained that failure of OPs to make the payment as per the actual loss tantamounts to unfair trade practice as defined under the provisions of Consumer Protection Act. Hence, this complaint is being laid by the complainant before this Commission for redressal of his grievances.


Accordingly, complaint is allowed and OP1 is directed as under:-

1. To pay Rs 5,00000/- (minus whatever has already been paid to the complainant) alongwith simple interest @ 9 % per annum.
2. To pay Rs 8,000/- {Rupees six thousand) as litigation

https://www.consumercourt.in/judgment/bajaj-allianz-general-insurance-co.-ltdanr._vs_ashiq-hussain-shah

---

Additional Tips​

• Maintain Records: Keep copies of all communications, documents, and acknowledgments.
• Timely Action: Adhere to the timelines specified for each redressal mechanism.
• Seek Clarifications: If any aspect of the rejection is unclear, request detailed explanations from the insurer.

---

Important Tip:
Before taking legal action, it is advisable to first send a legal notice to the Opposite Party.

Note:
We can assist in:

• Drafting professional legal notices.
• Filing consumer complaints for deficiency in service.

Feel free to contact us if you wish to proceed with a legal notice draft or complaint preparation.

Regards,
Support Team