Hemanshupuri Goswami alleges harassment and unfair practices by Care Health Insurance and Policybazaar over a rejected claim. Read the full complaint, policy details, and what customers must know before buying policies.
Complaint Summary : Care Health Insurance & Policybazaar.com Accused of Unfair Claim Rejection – Shocking Complaint by Hemanshupuri Goswami
| Detail | Information |
|---|---|
| Complainant | Hemanshupuri Goswami (Technology Lead, Ex-Infosys) |
| Company Involved | Care Health Insurance & Policybazaar.com |
| Issue | Rejected health insurance claim despite complete documentation |
| Policy Number | 8186781 |
| Complaint Type | Harassment, Unfair Claim Settlement, Claim Rejection |
| Key Concern | Claim denied citing unclear “Permanent Exclusion – Code Excl 04” |
| Platform of Purchase | Policybazaar.com |
| Status | Unresolved |
Full Write-Up
Background of the Complaint
Hemanshupuri Goswami, a seasoned IT professional, has raised a strong complaint against Care Health Insurance and Policybazaar.com regarding his recent claim experience. Despite paying premiums on time, he faced multiple hurdles in claim settlement, ranging from unnecessary document requests to outright rejection on vague grounds.
The Claim Process – From Cashless Denial to Harassment
- The complainant was hospitalized and filed a cashless claim, which was rejected by Care Health Insurance.
- He was then forced into the reimbursement process.
- During hospitalization, Care Health Insurance officials even questioned the authenticity of the hospital, asking for proof that it was “not fake.”
- Multiple visits and document submissions were made, including:
- Pre-hospitalization OPD records
- Investigation reports
- Indoor case papers
- Hospital registration documents
Despite all this, the insurer raised repetitive queries for the same documents again.
Final Claim Rejection – A Shock to the Customer
The claim was ultimately rejected on the grounds of “Permanent Exclusion Admission Primarily for Investigation and Evaluation (Code Excl 04).”
This reason was vague and unjustified, especially since the complainant was admitted for actual treatment and not for mere investigation. Such rejections raise serious questions about transparency in claim settlement.
Policybazaar’s Responsibility in the Issue
Since the policy was purchased via Policybazaar.com, the complainant expected the platform to intervene and ensure fair practices from their partner insurer. However, Policybazaar failed to provide meaningful support, which has further eroded consumer trust.
Consumer Rights & Legal Stand
Under IRDAI regulations, insurance companies cannot reject claims without valid reasoning and must clearly communicate exclusions in policy wording. Customers also have the right to escalate grievances to:
- IRDAI Grievance Cell (IGMS)
- Insurance Ombudsman
- Consumer Court, if harassment and unfair practices are proven
Why This Case is Important
This complaint highlights a growing concern in India’s health insurance sector:
- Unfair Claim Rejections: Policies sold but not honored during actual need.
- Lack of Accountability from Aggregators: Platforms like Policybazaar must ensure partner insurers act transparently.
- Mental & Financial Harassment: Customers face undue stress during medical emergencies.
Expert Suggestions for Affected Customers
If you face similar issues with Care Health Insurance or policies purchased through Policybazaar, here are the steps you should take:
- File a written grievance with the insurer and keep all acknowledgement numbers.
- Escalate to Policybazaar and demand intervention from their grievance redressal team.
- If unresolved within 30 days, escalate to IRDAI IGMS or the Insurance Ombudsman.
- For harassment and unfair practices, approach the Consumer Court for compensation.
Key Takeaways for Policy Buyers
- Always read policy exclusions carefully before buying.
- If purchasing via Policybazaar, demand strong after-sales support.
- Keep all written communications and documents ready for claim disputes.
- Remember, insurers are legally bound to honor genuine claims.
Frequently Asked Questions (FAQs)
Q1. Why was Hemanshupuri Goswami’s claim rejected by Care Health Insurance?
A: His claim was rejected citing “Permanent Exclusion Admission Primarily for Investigation and Evaluation (Code Excl 04),” which the complainant calls vague and unfair.
Q2. What role does Policybazaar play in this complaint?
A: Since the policy was purchased from Policybazaar.com, the platform is responsible for ensuring fair practices by its partner insurers. However, in this case, Policybazaar failed to provide effective support.
Q3. What is “Code Excl 04” in health insurance policies?
A: Code Excl 04 usually refers to permanent exclusion for hospitalization primarily for investigation and evaluation, but it should not apply if treatment is provided.
Q4. Can Care Health Insurance reject a claim even after all documents are submitted?
A: No, unless the claim falls under clear exclusions mentioned in the policy. Arbitrary rejections can be challenged under IRDAI and in consumer court.
Q5. What are the rights of a customer if their insurance claim is unfairly rejected?
A: They can escalate to the insurance ombudsman, IRDAI grievance cell, or file a consumer court case for harassment and financial losses.
Q6. Is Policybazaar responsible for claim settlement?
A: Policybazaar acts as a marketplace, not an insurer. However, it is expected to ensure its partner insurers handle claims fairly and provide customer assistance.
Q7. How long should a claim settlement take under IRDAI rules?
A: Insurers must settle claims within 30 days of receiving complete documentation.
Q8. What should customers do if asked for irrelevant documents repeatedly?
A: Escalate the matter immediately to IRDAI IGMS and keep records of harassment.
Q9. Can customers get compensation for delayed or rejected claims?
A: Yes, courts and IRDAI can award compensation if claims are wrongly rejected or delayed.
Q10. Should customers trust Care Health Insurance after this case?
A: Based on this complaint, caution is advised. Customers should evaluate reviews and complaints before purchasing.
Q11. Is it safe to buy policies from Policybazaar?
A: While Policybazaar is a leading platform, its lack of after-sales accountability raises concerns for some buyers.
Q12. What alternatives to Care Health Insurance exist in India?
A: Other reputed insurers include HDFC Ergo, ICICI Lombard, Star Health, and Max Bupa.
Q13. Can a rejected claim affect future claims?
A: No, each claim is assessed separately. However, repeated rejections may raise red flags.
Q14. How to file a complaint with IRDAI?
A: Customers can use IRDAI’s IGMS portal or call the grievance redressal helpline.
Q15. What is the Insurance Ombudsman’s role?
A: The Ombudsman is an independent body that resolves disputes between insurers and customers at no cost.
Q16. What happens if Policybazaar ignores a customer’s complaint?
A: The customer can directly escalate against the insurer and also hold Policybazaar accountable under consumer protection laws.
Q17. Can hospitals be blacklisted by insurers?
A: Yes, but insurers must provide clear proof. Customers have the right to demand transparency.
Q18. What is the difference between cashless and reimbursement claims?
A: Cashless means direct settlement between insurer and hospital, while reimbursement requires the customer to pay first and then claim.
Q19. What legal action can be taken for harassment by insurers?
A: Customers can approach consumer courts and claim damages for mental harassment and financial loss.
Q20. How can buyers avoid such issues in the future?
A: Choose insurers with strong claim settlement ratios, read terms carefully, and verify reviews before purchasing policies.
📌 Original Complaint Reference: [LinkedIn Post by Hemanshupuri Goswami]
