Gauri Shankar exposes how Care Health Insurance denied his cashless claim during emergency hospitalization at Fortis. Learn about his case, legal remedies, and consumer rights.
Complaint Summary
| Complaint By | Gauri Shankar Shukla |
|---|---|
| Company/Brand | Care Health Insurance |
| Product/Service | Health Insurance Policy – Cashless Claim |
| Complaint Type | Cashless Claim Denied / Harassment |
| Hospital Involved | Fortis Hospital |
| Issue Date | September 2025 |
| Complaint Status | Pending Resolution |
| Original Post Link | View LinkedIn Post |
Case Background
Health insurance is meant to provide financial relief during medical emergencies, not create additional trauma. Unfortunately, in the case of Gauri Shankar Shukla, his trust in Care Health Insurance was shattered when the company rejected his genuine emergency claim.
Mr. Shukla had been paying premiums regularly for 3 years, believing that when a real health crisis struck, his insurer would stand by him. But when he was admitted to Fortis Hospital with severe abdominal and spinal pain, diagnosed as Lumbar Vertebral Koch’s (Spinal Tuberculosis), Care Health Insurance refused to honor his cashless claim.
Key Issues Reported
- All required documents were submitted, including:
- Etiology note
- Duration & FCP of condition
- First consultation report
- Admission advice
- Claim delays & harassment: Despite complete documentation, Care Health Insurance kept delaying the process.
- Irrelevant document demands: The insurer insisted on a colonoscopy report—a test never advised by the treating doctors.
- Mental stress & financial strain: Instead of supporting the family during a crisis, the insurer created unnecessary hurdles.
- Systemic malpractice: This is not an isolated incident—many policyholders face similar issues where claims are denied to reduce payouts.
Steps Taken by the Complainant
- Submitted every required document to the insurer.
- Followed up multiple times with Care Health Insurance staff.
- Escalated the issue internally but received delays and no clarity.
- Decided to approach IRDAI and the Insurance Ombudsman.
- Made the issue public via LinkedIn to warn other consumers.
Steps the Brand Should Take to Regain Trust
For Care Health Insurance to resolve this issue and repair its reputation, the following corrective actions are necessary:
- Immediate Claim Approval – Process the pending cashless claim without further delay.
- Apology Letter – Issue a written apology to the complainant for mental and financial harassment.
- Compensation – Provide monetary compensation for stress and delay in treatment.
- Transparent Processes – Eliminate irrelevant document demands in future.
- Dedicated Emergency Cell – Create a 24×7 cell for urgent hospitalization claims.
- Employee Training – Ensure claim officers act with empathy and professionalism.
- Regulatory Compliance – Align claim processing with IRDAI guidelines.
- Quarterly Audits – Conduct independent audits to prevent malpractice.
What Legal Cases Can Be Filed Against Care Health Insurance?
If Care Health Insurance continues to ignore genuine claims, the complainant has strong legal remedies:
- Consumer Court Case (NCDRC, SCDRC, DCDRC): For deficiency in service and unfair trade practices.
- Insurance Ombudsman Complaint: For unfair rejection and unnecessary delays.
- IRDAI Escalation: Regulatory complaint for violation of insurance norms.
- Civil Lawsuit: For financial compensation due to stress, harassment, and delayed treatment.
- Criminal Case:
- IPC Section 420 – Cheating and dishonesty.
- IPC Section 406 – Criminal breach of trust.
- Writ Petition in High Court: For violation of Right to Life (Article 21) due to denial of emergency medical support.
- Medical Negligence Linked Case: If treatment was compromised due to claim denial.
- Collective Class Action: If multiple consumers report similar experiences.
Choice4Voice.com Intervention
At Choice4Voice.com, our mission is to stand with consumers when brands fail them.
- Featuring this case is the first step toward justice.
- If Care Health Insurance does not act promptly, Choice4Voice will:
- File a Consumer Court case on behalf of the complainant.
- Escalate the matter to IRDAI and the Insurance Ombudsman.
- Publish more awareness articles to expose malpractice.
- Provide legal guidance to the complainant.
- Connect with other affected consumers to build a stronger case.
Complaint Escalation Path
If the issue remains unresolved, the complainant can escalate step by step:
- Internal Escalation – Care Health Insurance Grievance Redressal.
- Insurance Ombudsman – Free and faster redressal mechanism.
- IRDAI Grievance Cell (IGMS) – Centralized complaint system.
- Consumer Court – For legal compensation.
- Civil Suit & Criminal FIR – If evidence shows fraud or cheating.
- Public Awareness Campaigns – Through media and social networks.
Advice for Consumers Facing Similar Issues
- Always maintain complete medical documentation.
- Record and store all communication with insurance staff.
- Never submit irrelevant or unadvised medical tests unless recommended by your doctor.
- Escalate within IRDAI timelines (30 days).
- If unresolved, file a Consumer Court case—many such cases result in refunds + compensation.
- Spread awareness on social media to pressure companies.
Q&A on Care Health Insurance Claim Issues
Q1. What is the main problem in this case?
A: Care Health Insurance rejected a genuine cashless claim during an emergency.
Q2. Who filed the complaint?
A: Mr. Gauri Shankar Shukla.
Q3. Which hospital was involved?
A: Fortis Hospital.
Q4. What was the diagnosis?
A: Lumbar Vertebral Koch’s (Spinal Tuberculosis).
Q5. What documents were submitted?
A: Etiology note, FCP, consultation, and admission advice.
Q6. What irrelevant document was demanded?
A: A colonoscopy report not advised by doctors.
Q7. How did this affect the patient?
A: Caused stress, financial worry, and delayed treatment risk.
Q8. What regulatory bodies can intervene?
A: IRDAI, Insurance Ombudsman, Consumer Court.
Q9. What legal actions are possible?
A: Consumer Court case, Ombudsman complaint, civil and criminal cases.
Q10. How can Choice4Voice.com help?
A: By publishing the case, guiding legal action, and escalating to regulators.
Q11. How should Care Health Insurance resolve this?
A: Approve claim, apologize, compensate, and improve policies.
Q12. What rights do policyholders have under IRDAI?
A: Right to timely claim settlement, transparency, and grievance redressal.
Q13. What timelines does IRDAI prescribe for claim settlement?
A: Maximum of 30 days for claim processing.
Q14. What is the role of the Insurance Ombudsman?
A: Independent body resolving disputes quickly and free of cost.
Q15. Can this be considered harassment?
A: Yes, denial of genuine claims during emergencies is harassment.
Q16. What financial remedies are available in Consumer Court?
A: Claim reimbursement + compensation + litigation cost.
Q17. Can Care Health Insurance face penalties from IRDAI?
A: Yes, for regulatory non-compliance.
Q18. What preventive measures should customers take?
A: Verify claim settlement ratios before buying insurance.
Q19. Is public awareness effective?
A: Yes, it pressures companies to resolve faster.
Q20. What is the next step if no resolution comes?
A: Legal filing by complainant or Choice4Voice.com legal team.
✅ Final Note: This case is now officially featured on Choice4Voice.com. If Care Health Insurance fails to resolve, we will escalate legally and publicly for the complainant’s justice.
