In India, the decision to hospitalize a patient is increasingly being made by health insurance companies rather than doctors. This was the experience of Syam Krishna, a 34-year-old Assistant Commandant in the CRPF, whose four-and-a-half-year-old autistic son, Samarth, fell critically ill in a remote town in Meghalaya. Afterinitial consultations at the local district hospital, Samarth’s condition worsened, and his parents decided to take him to a hospital in Guwahati, a six-hour journey away.
At Apollo Excel Care Hospital, doctors found Samarth’s condition serious enough to warrant immediate admission, and he was treated for viral fever with dehydration. However, when Syam submitted a cashless claim to Care Health Insurance, the insurer rejected it, stating that hospitalization “was not required.” The company claimed that Samarth’s admission was only for evaluation, not treatment, and questioned the family’s claim history, insinuating possible misuse of the policy.
Syam felt cheated and stressed that he and his wife, Spoorthi, had followed the doctor’s medical advice and had no choice but to consult the local hospital first. He argued that the insurer’s decision was wrong and that they were being penalized for making genuine claims in the past. The family eventually approached the Insurance Ombudsman, who ruled in their favor, stating that the denial of the claim was “totally unwarranted and defies logic.” The insurer was ordered to pay the claim amount of Rs 42,907, along with 7.25% interest.
This case highlights a larger issue in India’s health insurance ecosystem, where policyholders often face procedural hurdles and emotional exhaustion despite following every required step. According to the IRDAI Annual Report for FY2023-24, health insurers rejected or disallowed claims worth over Rs 26,000 crore, an increase of around 19% from the previous year. The case also raises questions about the balance of power between insurers, hospitals, and policyholders, with industry observers noting that disputes between insurers and hospitals over the necessity or cost of treatment are common.
Syam’s experience reflects a pattern of claim denial, where insurers often cite inflated billing and non-essential admissions, while hospitals defend their decisions as clinical judgment. In the end, it is often the policyholder who bears the uncertainty and delay. Syam’s story is part of a larger series highlighting cases where individuals and families have faced undue health insurance claim rejections, and it serves as a warning to others to be aware of their rights and to fight for them when necessary.