Repudiation of Claim of Health Insurance of Shri Hridhaan Bhushan Yadgirwar

Sir/Madam :
Below are the details of the claim raised for hospitalization of My Son for his illness
Name of Complainant : BHUSHAN M YADGIRWAR
Claim Intimation Number : CIR/2023/151134/0975257
Name of the insured-Patient : HRIDHAAN BHUSHAN YADGIRWAR
Age / Sex : 3 years / Male
Product name : Family Health Optima Insurance Plan
Policy Number : P/151134/01/2022/005731
Name of Insurance Company: STAR HEALTH AND ALLIED INSURANCE CO. Ltd
Policy period : From : 30-Oct-2021 To : 29-Oct-2022
Diagnosis : Viral Infection
Date Of Admission : 22-Oct-2022
Name of Hospital and Location : Kilbil Hospital-290/6 Plot no.2 Near Patil Electronics Institute, Bhosale Mala, New Radhika Rd, Karanje Turf Satara, Satara, Maharashtra 415002

Reason For rejection as given by Insurer : It is observed from the submitted records that the insured patient was admitted and treated in a medical facility, which is not fulfilling the criteria defined to be a hospital in the policy.

My Grievance for getting claim amount
1) Claim intimation on time
2) Claim form with all relevant bills and documents submission on time
3) IPD papers, investigation reports and OPD papers prior to hospitalization submitted with claim form.
4) Kilbil Children's Clinic Satara is a Registered Hospital with Registration No SAT/91 under Bombay Nursing Home Registration Act 1949. The Registration certificate was issued by Civil Surgeon
5) Below are the details of claims approved by other insurance companies when patient was admitted at same hospital where my son was admitted at Kilbil Children's Clinic Satara

 Name of patient : Jadhav Aaranya Dnyaneshwar
 Name of Insured : Jadhav Dnyaneshwar Sopan
 Policy Number : 161200/48/22/0296
 Claim Intimation number : CCNMDI7384092
 Claim Amount Rs 42,306/-
 Name of Insurance Company : MD India health Insurance TPA private limited
I have protested against the same with the Grievance Management Cell of the STAR HEALTH AND ALLIED INSURANCE CO. Ltd , however, by an e-mail dated 21.11.22 and 22.11.2022 , the same was again rejected.
As per your brochure terms to be a Hospital:
A hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under Clinical Establishments (Registration and Regulation) Act 2010 or under enactments specified under the Schedule of Section 56(1) of the said act
Or
complies with all minimum criteria as under:
i) has qualified nursing staff under its employment round the clock;
ii) ii) has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;
iii) iii) has qualified medical practitioner(s) in charge round the clock;
iv) iv) has a fully equipped operation theatre of its own where surgical procedures are carried out;
v) v) maintains daily records of patients and makes these accessible to the insurance company's authorized personnel;
please mention in which condition the said hospital (Kilbil Hospital-290/6 Plot no.2 Near Patil Electronics Institute, Bhosale Mala, New Radhika Rd, Karanje Turf Satara, Satara, Maharashtra 415002) does not fulfill the condition to be a hospital. I context to this is the article published in news paper
On 5th July, IRDA told the Bombay High Court that it has withdrawn the bed restriction clause. The hospitals will need to be registered with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010, or under the enactments specified under the Schedule of Section 56(1) of the said Act.
As per IRDAI regulations company forms a Policyholder Protection Committee in the Board of Directors. I am not getting any reply from Policyholder Protection Committee.
So it is kindly requested to give directives to STAR HEALTH AND ALLIED INSURANCE CO. Ltd for settlement of my claim.


Yours sincerely

B.M.Yadgirwar