u/Complex_Particular65

My uncle has star health insurance and paying all timely premiums since last 10 years. Yesterday my uncle slipped at home and fractured his Femur bone. I went to show my uncle at Star Health panel hospital where cashless treatment is allowed. Doctor did a regular blood test and x-ray and then forwarded case to PAC (Pre-Anesthetic Checkup) before Surgery to fix the bone . In PAC, all the basic details were noted by doctor before a surgery. Then hospital submitted case for cashless treatment approval to star health after submitting an estimate and other documents.

Star health with 20 minutes rejected the claim by picking a point from PAC where all the basic details mentioned such as no medications, allergy, lifestyle and 'socially consume alcohol' and quoted following:

"Based on the submitted medical records, it has been observed that the insured patient has undergone treatment for a condition resulting from the use of alcohol, drugs, or substance abuse. As per Alcoholism, drug or substance abuse Exclusion Code 12, the policy excludes coverage for any expenses incurred for treatment related to alcoholism, drug or substance abuse, or any addictive condition and its consequences. Therefore, we regret to inform you that the claim is not admissible."

There was nothing to substantiate to this reason in the documentary form such as in the blood test or anything. Now what to do because it is very illogical because the cause of fall is nowhere written as under influence of alcohol. We went ahead for surgery by bearing all the cost from the pocket. Please advise what should i do?

Edit: i have 2 choices either i get remark from PAC doctor that he wrote down 'social' in alcohol column due to mis communication and state there is no alcohol history.

Or i get remark from ortho doctor who did surgery that there is no alcohol sign in patient and in his blood reports which may relate to this injury. (This time we may get claim but in future, there are chances if we go for any heart, liver ir other related issue, They will outrightly deny the claim stating this 'social' remark in PAC report.

Please guide with which option i should go?

https://preview.redd.it/wc2uhmxfi2kh1.png?width=996&format=png&auto=webp&s=7a46da560ad9deeb94beaf0ea77a79567186e4b7

My uncle has star health insurance and paying all timely premiums since last 10 years. Yesterday my uncle slipped at home and fractured his Femur bone. I went to show my uncle at Star Health panel hospital where cashless treatment is allowed. Doctor did a regular blood test and x-ray and then forwarded case to PAC (Pre-Anesthetic Checkup) before Surgery to fix the bone . In PAC, all the basic details were noted by doctor before a surgery. Then hospital submitted case for cashless treatment approval to star health after submitting an estimate and other documents.

Star health with 20 minutes rejected the claim by picking a point from PAC where all the basic details mentioned such as no medications, allergy, lifestyle and 'socially consume alcohol' and quoted following:

"Based on the submitted medical records, it has been observed that the insured patient has undergone treatment for a condition resulting from the use of alcohol, drugs, or substance abuse. As per Alcoholism, drug or substance abuse Exclusion Code 12, the policy excludes coverage for any expenses incurred for treatment related to alcoholism, drug or substance abuse, or any addictive condition and its consequences. Therefore, we regret to inform you that the claim is not admissible."

There was nothing to substantiate to this reason in the documentary form such as in the blood test or anything. Now what to do because it is very illogical because the cause of fall is nowhere written as under influence of alcohol. We went ahead for surgery by bearing all the cost from the pocket. Please advise what should i do?

Edit: i have 2 choices either i get remark from PAC doctor that he wrote down 'social' in alcohol column due to mis communication and state there is no alcohol history.

Or i get remark from ortho doctor who did surgery that there is no alcohol sign in patient and in his blood reports which may relate to this injury. (This time we may get claim but in future, there are chances if we go for any heart, liver ir other related issue, They will outrightly deny the claim stating this 'social' remark in PAC report.

Please guide with which option i should go

My uncle has star health insurance and paying all timely premiums since last 10 years. Yesterday my uncle slipped at home and fractured his Femur bone. I went to show my uncle at Star Health panel hospital where cashless treatment is allowed. Doctor did a regular blood test and x-ray and then forwarded case to PAC (Pre-Anesthetic Checkup) before Surgery to fix the bone . In PAC, all the basic details were noted by doctor before a surgery. Then hospital submitted case for cashless treatment approval to star health after submitting an estimate and other documents.

Star health with 20 minutes rejected the claim by picking a point from PAC where all the basic details mentioned such as no medications, allergy, lifestyle and 'socially consume alcohol' and quoted following:

"Based on the submitted medical records, it has been observed that the insured patient has undergone treatment for a condition resulting from the use of alcohol, drugs, or substance abuse. As per Alcoholism, drug or substance abuse Exclusion Code 12, the policy excludes coverage for any expenses incurred for treatment related to alcoholism, drug or substance abuse, or any addictive condition and its consequences. Therefore, we regret to inform you that the claim is not admissible."

There was nothing to substantiate to this reason in the documentary form such as in the blood test or anything. Now what to do because it is very illogical because the cause of fall is nowhere written as under influence of alcohol. We went ahead for surgery by bearing all the cost from the pocket. Please advise what should i do?

Edit: i have 2 choices either i get remark from PAC doctor that he wrote down 'social' in alcohol column due to mis communication and state there is no alcohol history.

Or i get remark from ortho doctor who did surgery that there is no alcohol sign in patient and in his blood reports which may relate to this injury. (This time we may get claim but in future, there are chances if we go for any heart, liver ir other related issue, They will outrightly deny the claim stating this 'social' remark in PAC report.

Please guide with which option i should go?

https://preview.redd.it/4l127cq2j2kh1.png?width=996&format=png&auto=webp&s=97a319b37998124c307ad3fa96cc2d987a790ce5