Claim denials
Medical necessity denials
A treating doctor admits the patient. The insurer's medical team, which has not seen the patient, decides the admission was not necessary. These denials substitute a remote opinion for a clinical one.
Health insurance
Cashless Claim Denied Under "Investigation and Evaluation" Exclusion Despite Acute Emergency Symptoms
A policyholder's wife was admitted as an emergency with breathing difficulty, severe abdominal pain, and acute headache, yet the insurer rejected the cashless claim citing a permanent exclusion for admissions primarily for investigation and evaluation.
Health insurance
Cashless Claim Denied During Dengue Scare: When Insurers Second-Guess Doctors
A policyholder admitted to hospital on a doctor's explicit advice for persistent high fever was twice refused a cashless claim on grounds of "medical necessity not established," forcing full out-of-pocket payment despite clear clinical documentation.