Denied in crisis: Inside a family’s year-long fight for health insurance

In April 2024, when Vipin Vishnu Ajayan’s father suffered severe chest pain, the family trusted their recently purchased Health policy to cover the treatment. With an annual premium of around Rs 32,000, the plan promised Rs 5 lakh coverage for both parents. But instead of financial relief, the family faced a year-long battle of repeated denials, unclear communication, and delayed payments.

Doctors diagnosed multiple cardiac blockages and recommended stent procedures. Hoping for cashless treatment at a network hospital, the family admitted him—only to be denied. The insurer cited “insufficient records” and advised them to seek reimbursement later. With no other option, Vipin borrowed money from friends and his sister to cover the immediate expenses.

Distress and Denial

Star Health, in a statement to IndiaToday.in, explained that claim rejections often arise from non-disclosure of pre-existing conditions. The insurer argued that Vipin’s father’s case was medically improbable: “Within three months of policy purchase, a claim was filed for a 60-year-old male admitted with triple vessel Coronary Artery Disease (CAD), with only one month of symptoms. Medically, this is highly improbable.”

Vipin disputes this reasoning. Despite submitting complete documentation, including a cardiologist’s note confirming no prior history of heart disease, the claim was repeatedly denied. “They kept asking for more documents but sent the same rejection each time. A heart attack doesn’t give warnings—so how can they call it pre-existing?” he asked.

Vipin also questioned why Star Health later offered a partial settlement before the Ombudsman hearing if they believed the claim was invalid. “It contradicts their own stance and shows they acted only after constant follow-ups. It felt like unnecessary delays meant to wear us down,” he said.

He highlighted gaps in the sales process as well: “At the time of purchase, I was asked about my parents’ health honestly. That was accepted then. Why doubt the same answers when it came to a claim? It shows a focus on selling policies rather than standing by customers when it matters most.”

Ombudsman Steps In

By November 2024, Vipin approached the Insurance Ombudsman. Before the hearing, the insurer offered a partial settlement of Rs 1,03,859 with 8.75% interest from July 3, 2024. While the claim was finally processed, his father had also been removed from the policy without proper notice, forcing further appeals. The Ombudsman directed the insurer to reinstate coverage, which was eventually honored.

Despite complying with the Ombudsman’s decision, Star Health maintained its stance that the case reflected “non-disclosure,” saying: “Triple vessel CAD without prior symptoms in this short duration is unlikely.” Vipin, however, felt the company’s customer service was equally troubling. “Calls went unanswered, agents blocked me, and I was even dismissed at the Ombudsman’s office. Families should not have to fight this hard for rightful claims,” he said.

What Policyholders Can Do

According to Abhishek Kumar, Sebi RIA and founder of SahajMoney, cases like Vipin’s are common. He recommends that policyholders:

• Keep detailed medical and claim records
• Request pre-authorization for cashless treatment
• Demand written explanations for rejections citing policy terms
• Escalate to the insurer’s grievance desk and nodal officer
• If unresolved in 30 days, file complaints on the Bima Bharosa portal or approach the Insurance Ombudsman
• As a last resort, consider filing in Consumer Court

On cancellations, he explained: “Insurers can only cancel policies for proven fraud or misrepresentation, with at least seven days’ notice. Policyholders can demand reinstatement if wrongly removed, escalating if necessary.”

While IRDAI mandates faster claim processes—like one-hour decisions for cashless authorization and three-hour discharge approvals—Kumar cautions that real-world delays remain common. “Insurers often stall to frustrate policyholders into giving up,” he said.

For Vipin and his family, the experience was financially and emotionally draining. What should have been a lifeline in a medical emergency instead turned into a year-long fight for justice. The case underscores that an insurance premium’s true worth lies not in its promise, but in an insurer’s willingness to deliver when families need it most.