My mothers insurance claim was short settled & ICU charges was not considered

Dear Client,
Your situation highlights the inconsistency and unfairness in the insurance provider's handling of your mother's claim. Initially, they approved the cashless claim twice, indicating that ICU admission and the associated treatments were justified. Denying the reimbursement later and excluding significant charges like ICU, oxygen, and major medicines contradicts their earlier approvals and seems unjustifiable.
Under the Insurance Regulatory and Development Authority of India (IRDAI) guidelines, you have the right to seek redressal for such grievances. You can file a complaint with the Insurance Ombudsman, providing all relevant documents, including initial approvals, hospital bills, and correspondence with the insurance company. The Ombudsman can help resolve disputes regarding claims up to ₹30 lakhs. Additionally, you can consider filing a consumer complaint under the Consumer Protection Act, 2019, for deficiency in services and unfair trade practices. Consulting a legal professional specializing in insurance claims can further assist you in preparing and filing your case to ensure you receive the entitled reimbursement.

Dear Client,
The terms and conditions of an insurance policy are the most crucial and vital to go through before raising a claim against the policy. Based on the self-declaration of the policy buyer, the risk and coverage are underwritten and the premium is calculated by the underwriter of the Insurance Company following the guidelines of the regulatory authority IRDAI. Despite non-disclosure of Pre-Existing diseases (PED), some PEDs are covered by continuous renewal of the policy for two or four years from the date of inception of the policy. If any claim is raised before it comes under the coverage on continuous renewal of the policy for prescribed periods, the insurer repudiated the claim of the insured on the grounds of non-disclosure of PED while buying a health insurance policy. A group health insurance policy typically covers ICU charges. These policies are designed to provide comprehensive health coverage for employees, including costs associated with intensive care units (ICUs). From the query, it transpires that you have already exhausted the internal grievance redressal mechanism that repudiated your insurance claim. So, in the given scenario, approaching the Ombudsman for relief may not yield any fruitful result, instead, it may kill time to make your claim barred by limitation before the Consumer Court. A complaint before the Consumer Court is required to be filed within two years from the date of cause of action i.e, the date of repudiation of claim by Insurer. So, in the given situation, serving a legal notice to the Insurance company a complaint over alleged deficiency in service and unfair trade practices under Sec.35 of the Consumer Protection Act, 2019 should be filed before the Dist. Consumer Commission claiming the amount repudiated by the Insurer along with interest and compensation for harassment and mental agony. Reach out to an Advocate experienced in consumer court cases for advice and action ASAP.

Dear Sir,
You may get issue legal notice and thereafter approach Insurance Ombudsman and if matter not settled then approach Consumer forum.