Hdfc ergo health insurance claim denied
Wife (27/F) and me (33/M) took hdfc ergo optima secure health insurance in March 2023 thru their website directly. Both of us have no comorbidities. On oct 26th 2023 wife develops high fever, cough, hypotension, tachycardia and is admitted in a reputed network hospital and diagnosed with pneumonia and UTI. We file a claim for cashless facility and it gets denied citing "No indication for hospitalization"
The doc sends a letter indicating the disease is serious and needs hospitalization. Claim still denied citing same reason. Her condition worsens, needs IV antibiotics 3 times a day, CT scan is done, blood culture is positive. We send all these reports and another letter from the doctor and STILL they deny insurance citing they don't find any reason for hospitalization!!!???
Wtf? What more reason do they want?! Customer care is not helpful either.. what do I do next? I've already sent them an official mail but no response still.. And I thought hdfc ergo was a trustworthy one with 100%* claim settlement ratio blah blah. Really disappointed
Update: (1/11)wife is recovering well. Planned for discharge only after 3 more days in view of IV antibiotics. Received a call back from the grevience cell of hdfc saying they will look into the matter again. Meanwhile I have sent mails to all levels of escalation mentioned in comments. My family members say irdai and ombudsman are going to take time, rather send a legal notice to hdfc. That should make them understand that I'm not backing off so easily. Planning for that tomo.
Update 2 (1/11): got an email stating cashless approval has been sanctioned (hurray!) for 25k. (Present bill is 80k for 1 week of treatment). The pdf of the mail states that duration of stay is estimated as 2 days (its already a week) and the approval was sanctioned within 8 minutes of reciept of claim (the audacity!) Planning to send another letter stating what all happened this entire week and asking for enhanced approval amount.
Update 3 (3/11): so with another letter stating the condition, sanction of 85k came with ease. Wife is still in hospital. Discharge is planned only after 4 days more.
Update 4 (7/11): Finally treatment is done, wife is getting discharged. Enhancement letters sent until now (after the multiple complaint mails to the grevience officer) are being sanctioned without any queries. The final discharge bill was also fully paid by hdfc cashless :)
Thankyou for all the opinions and points suggested in comments. Thankfully, a complaint mail to hdfc was sufficient to take care of the issue and I dint have to escalate it further.