Navneet Mohanty
New member
- Policy Name
- Aditya Birla Health Insurance- Group Activ Health plan; GHI-91-25-1212794-000,2-91-25-0001906-000
- Company Name
- Aditya Birla Health Insurance Co. Limited
- Customer Care Number
- 1800 270 7000
- Loss Amount
- 103741
- Ratings
- Opposite Party Address
- Aditya Birla Health Insurance Co. Limited
One World Centre, Tower 1,
Jupiter Mills Compound,
841, Senapati Bapat Marg,
Elphinstone Road,
Mumbai – 400013, Maharashtra, India
I am filing this complaint against Aditya Birla Health Insurance Co. Limited regarding the wrongful rejection of my reimbursement claim under the Group Activ Health Plan.
Policy Number: GHI-91-25-1212794-000 / 2-91-25-0001906-000
Claim ID: 1222685507656
The patient, Ms. Jagriti Shahi, was admitted to Annapurna Hospital, Gorakhpur, from 7 July 2026 to 10 July 2026 due to severe abdominal pain. Despite continuous inpatient treatment, her condition did not improve, and she was referred to Max Hospital, Lucknow, for higher medical management, as clearly recorded in the discharge summary.
At Max Hospital, the patient required hospitalization and was admitted to the ICU for approximately 24 hours plus in the ward from 10th July to 14th July. During the hospitalization, she underwent extensive diagnostic investigations, including CRP and other blood tests, CT Scan, MRI, Endoscopy, X-ray, Ultrasound, and other laboratory investigations. She also received continuous monitoring, intravenous medications, injections, and specialist care.
The reimbursement claim was submitted along with all relevant supporting documents, including the treating doctor's justification letter, ICU face sheet, discharge summaries, indoor case papers, investigation reports, treatment records, and hospital bills.
However, Aditya Birla Health Insurance rejected the claim stating:
"On review of the submitted claim documents, it is observed that the present hospitalization doesn't warrant inpatient admission and could have been managed on an OPD basis. Hence, this claim is inadmissible under Clause IV.B – Specific Exclusions: Any treatment or part of a treatment that is not of a reasonable charge, is not a Medically Necessary Treatment."
I believe this decision is arbitrary and contrary to the medical evidence submitted. The treating physicians, who personally examined and managed the patient, determined that hospitalization was medically necessary. The patient required ICU care, extensive diagnostic investigations, continuous inpatient monitoring, and specialist treatment. Additionally, the patient had already undergone hospitalization at Annapurna Hospital without recovery and was referred to a higher medical centre due to the seriousness of her condition.
Despite these facts, the insurer has neither explained the medical basis for concluding that the hospitalization was unnecessary nor clarified how the patient's condition could reasonably have been managed on an outpatient basis.
I respectfully request that Aditya Birla Health Insurance review the claim based on the complete medical evidence, provide a detailed medical justification for the rejection, and approve the reimbursement claim if found admissible. If the insurer continues to deny the claim, I request a reasoned speaking order explaining the medical and policy basis for its decision with reference to the documents submitted.
I seek reimbursement of the eligible hospitalization expenses incurred at Max Hospital, Lucknow, along with any other relief deemed appropriate under the circumstances.
Policy Number: GHI-91-25-1212794-000 / 2-91-25-0001906-000
Claim ID: 1222685507656
The patient, Ms. Jagriti Shahi, was admitted to Annapurna Hospital, Gorakhpur, from 7 July 2026 to 10 July 2026 due to severe abdominal pain. Despite continuous inpatient treatment, her condition did not improve, and she was referred to Max Hospital, Lucknow, for higher medical management, as clearly recorded in the discharge summary.
At Max Hospital, the patient required hospitalization and was admitted to the ICU for approximately 24 hours plus in the ward from 10th July to 14th July. During the hospitalization, she underwent extensive diagnostic investigations, including CRP and other blood tests, CT Scan, MRI, Endoscopy, X-ray, Ultrasound, and other laboratory investigations. She also received continuous monitoring, intravenous medications, injections, and specialist care.
The reimbursement claim was submitted along with all relevant supporting documents, including the treating doctor's justification letter, ICU face sheet, discharge summaries, indoor case papers, investigation reports, treatment records, and hospital bills.
However, Aditya Birla Health Insurance rejected the claim stating:
"On review of the submitted claim documents, it is observed that the present hospitalization doesn't warrant inpatient admission and could have been managed on an OPD basis. Hence, this claim is inadmissible under Clause IV.B – Specific Exclusions: Any treatment or part of a treatment that is not of a reasonable charge, is not a Medically Necessary Treatment."
I believe this decision is arbitrary and contrary to the medical evidence submitted. The treating physicians, who personally examined and managed the patient, determined that hospitalization was medically necessary. The patient required ICU care, extensive diagnostic investigations, continuous inpatient monitoring, and specialist treatment. Additionally, the patient had already undergone hospitalization at Annapurna Hospital without recovery and was referred to a higher medical centre due to the seriousness of her condition.
Despite these facts, the insurer has neither explained the medical basis for concluding that the hospitalization was unnecessary nor clarified how the patient's condition could reasonably have been managed on an outpatient basis.
I respectfully request that Aditya Birla Health Insurance review the claim based on the complete medical evidence, provide a detailed medical justification for the rejection, and approve the reimbursement claim if found admissible. If the insurer continues to deny the claim, I request a reasoned speaking order explaining the medical and policy basis for its decision with reference to the documents submitted.
I seek reimbursement of the eligible hospitalization expenses incurred at Max Hospital, Lucknow, along with any other relief deemed appropriate under the circumstances.