Merupula Madhu

An insurer initially rejected a client’s hernia surgery claim, pointing to old health check-up reports that showed high cholesterol levels. They attempted to classify this as a non-disclosed pre-existing condition. We challenged the decision and established that the cholesterol history had no medical connection with the surgical claim.

A client was admitted for a planned single knee replacement surgery. During the procedure, the operating surgeon discovered unforeseen medical severity that changed the surgical requirements. Additional treatment was medically necessary, which created questions around coverage. Updated clinical justification was provided while coordinating with the hospital and insurer.

Two children were hospitalized for Dengue. One claim was processed quickly, while the second remained delayed due to an incorrect field-verification process. The issue was escalated through the claims channel and an urgent online verification was coordinated using real-time medical and supporting documentation.

A client suffered a severe knee injury in an accident, but the insurer rejected the claim by applying a standard waiting-period clause. The policy wording was reviewed and it was established that treatment arising from an accident was not subject to the waiting-period restriction being applied to the claim.

A woman’s uterus removal claim was rejected because an old prescription mentioned irregular periods. The insurer attempted to link the historical note with the current medical condition. The medical connection was challenged, supporting records were presented and the matter was escalated through the grievance process and Ombudsman.