Your surgeon recommended laparoscopic gallbladder surgery. CareShield's AUTH-AI bot denied cashless hospitalisation: "Not medically necessary. Conservative management recommended." No one from the insurer examined you.
IRDAI Fair Claim Settlement
IRDAI (Health Insurance) Regulations require insurers to establish fair, transparent claim procedures. Denials must cite specific reasons and be subject to grievance redressal. IRDAI
Your Treating Doctor Matters
Automated clinical guidelines cannot override a treating physician's recommendation without independent review of your records. Demand the insurer address your diagnosis and reports — not generic policy rules.
Escalation Path
- Written grievance to insurer's grievance officer with surgeon's letter and diagnostics.
- Request independent medical review by qualified insurer physician.
- Insurance Ombudsman — cioins.co.in (free).
- Consumer forum for deficiency of service if unresolved.
Frequently Asked Questions
Can insurers deny without reviewing my doctor?
Challengeable — IRDAI requires fair settlement; denials need specific clinical reasoning.
How do I escalate?
Internal grievance → Insurance Ombudsman → consumer forum.
What is pre-auth denial?
Refusal of cashless approval before treatment — forcing upfront payment.
Related Guides
Practice against CareShield's AUTH-AI — cite IRDAI and your surgeon's recommendation.
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