Truth Triumph! Tenacious fight to get my 2 months infant surgery's valid medical claim approved after 7 denials

It is a 100% real experience that I share on how often we lose our rightful ask just because some few initial steps do not work in our favour. My aim is not to blame my employer they are wonderful in ensuring that employees get best welfare schemes however I still want to share my experience so that others take inspiration to fight for the rightful ask and explore solutions in the redressal bodies.

I want to share the recent experience I had while availing my employer's Health Insurance Scheme ( hereafter referred as 'HIS') that facilitates employees for Medical cover against illness. HIS has numerous success stories for giving employees with good health care service, however this particular case was a not so pleasant one nevertheless all is well that ends well.

On June 1st 2022, my 2 months old infants started excessive crying after few failed efforts to make the infant at ease I decided to rush for Hospital, I ensured the hospital is one that qualifies under cashless facility of HIS, as soon as Doctors assessed the baby they concluded to carry out an emergency surgery to correct the?Inguinal Hernia - The Ailment is Inguinal Hernia.

An Emergency Surgery was performed on 2 June 2022 at 2:00 am IST after which the baby was at ease and relived. The doctor decided that they will discharge the baby on 3rd June 2022 morning.

HIS Medi Assist Barbarism starts:

On 2nd June 2022 evening an email lands that my cashless claim(A facility by HIS to get free of cost or large cost covered hospitalization) is denied because ailment Hernia is an external Congenital diseases meaning Hernia is a birth-defect. I consulted the team of doctors at hospital they assured that Hernia is not a birth defect and insurance company's reason for denial is incorrect medically. I checked it with multiple doctors everyone said hernia is not a birth-defect, then why HIS Team denied cashless claim on wrong reason.

Later I also referred most recent HIS Policy document where it was clearly mentioned that Hernia is included in the Policy, still my claim got denied with an incorrect reason.

After all this checks I again called HIS Team which is externally managed by Medi Assist Healthcare Limited they said Yes Hernia surgery is covered in policy Terms and conditions and I need to re-submit cashless claim for re-consideration and my claim will approve however it again got denied with same reason as before. I was suffering so badly even when I was absolutely correct for my ask.

Anyways my struggle for claiming a valid claim continued on the day of discharge i.e. 3rd June 2022, the discharge was supposed to happen at 10am IST however I kept on chasing the Medi Assist Team and my claim got denied again and again (Yes 2 times in 1 day and 4 times in 2 days), finally my patience was lost, I decided to pay from my pocket the entire bill and get my infant son discharged with a delay of 8+ hours, Yes my 2 months old infant has to suffer a delay of 8+ hours due to Medi Assist Team repeatedly denying my perfectly valid claim.

Furious at this incident of Medi Assist, I shared my experience with Corporate HIS (A Team who looks for governance in HIS Operations) they informed me they will look into it and asked to re-raise the claim and keep them informed. To my shock my claim again got denied this was 5th time, I informed HIS and they said they will look into it and asked to re-raise the reimbursement claim and to my immense shock it again got denied for 6th Time, this time I lost my tolerance, because Wrong is Wrong how can I be denied a claim which is 100% valid, I along with ongoing HIS team raised the matter with the Insurance Company Grievance Team sadly I had no response from them. My employer's HIS Team informed they are looking into the matter and asked to re-raise the claim but old story repeats claim again got denied 7th time. I raised a complaint against the Insurance company and TPA- Medi Assist in India's National Consumer Forum, this time something strange happens I get a response the insurance company the very next day my claim gets approved and in 2 days payment also gets credited to my bank account finally my claim gets approved settled and suddenly in the science of Insurance company the ailment is no longer a birth defect. Thanks to never ending efforts of my employer's Corporate HIS and also National Consumer Forum.

I am happy that my perfectly valid claim is at last approved but?am happier to see that the rights of consumer are protected?though they need to run corner to corner. I was very disheartened when few folks said once claim is repeatedly denied there is no chance, my disappointment was not for losing the money but for the fact that a consumer who is absolutely right in his/her ask has no control over the service provider. I am happy that the complaint System works. Lastly am happiest because my child is also doing far better in terms of health.

Impact of my case: My employer updated the HIS Policy and subjectively included the case of Hernia in children the revised policy will be made valid in few days.

Few Learnings from my experience:

• If you are right in your ask be string enough to put a dent in the universe but follow the regulations and rules.
• Please Read your policy document very careful
• Most important learning always complaint and raise your voice in every possible forum.

I hope this article and my true case inspires others to fight for their rightful ask.