Introduction:
Some claims are denied with a keystroke. Others are fought for line by line, word by word, until justice is done. This is the story of a renowned general physician from Bengaluru, who found himself defending a routine hospitalisation claim for his wife… all because of a back surgery she had 15 years ago.
The hospital bills were real, and the treatment was necessary. But the insurer raised a hand, and the claim hit a wall. That’s when CoverYou stepped in. Not with anger, but with the law.
Case Background:
On May 15, 2025, the doctor’s wife was admitted to the Hospital with a diagnosis of ACL tear with medial meniscus tear. A cashless claim was filed under their health insurance plan. The hospitalisation was medically justified and straightforward. But mid-process, the insurer raised a red flag. They brought up a laminectomy surgery done in 2010, a full 15 years ago, and asked for its records, claiming it had not been disclosed.
The doctor didn’t have the papers anymore. Understandably so, who does after a decade and a half? But the insurer wasn’t ready to move forward without them.
Incident Report:
Date of Hospitalisation: May 15, 2025
Hospital: One of the renowned hospitals in Bengaluru
Diagnosis: ACL + Medial Meniscus Tear, and the Claim type? It was cashless
Insurer’s Objection:
- The Insurer referred to a 2010 laminectomy as an “undisclosed” past condition and demanded full medical records from 15 years ago, and threatened to deny the claim due to “non-disclosure.”
Doctor’s Situation:
- The doctor has no access to those old records, and the surgery is not relevant to the current diagnosis. The Arthritis and hip replacement had already been disclosed earlier as PEDs.
Support from CoverYou:
At this point, the doctor contacted us, and our health claim expert took the lead. She advised the doctor to obtain a certificate from the hospital where the 2010 procedure was done, confirming the facts. Simultaneously, we helped draft a formal self-declaration stating:
- The past surgery was not intentionally withheld.
- It had no relevance to the current ACL tear.
- Most importantly, under IRDAI’s 5-Year Moratorium Rule, no insurer can deny a claim for non-disclosure of a condition after 5 years unless there is proven fraud.
This wasn’t fraud, but it was a doctor doing his best, with full disclosure, and a family member in pain.
Claim Outcome:
- The claim has been approved with the full amount sanctioned, and the settlement amount was cashless with no deductions. The resolution timeline of the case was within the standard processing period.
- Client Feedback: A heartfelt video testimonial from a doctor thanking the CoverYou team
Impact:
This case wasn’t just about money, but it was about fairness. About reminding the insurer of the very rules they are bound to follow. For every doctor who trusts us with their family’s care, we offer more than just paperwork; we offer protection that’s informed, compassionate, and relentless.
Disclaimer:
This case study has been anonymised where necessary to protect client privacy. All details are factual by making the client anonymous.
