Janta Ka Mudda has received a representation from Ms. Akansha Srivastava, who has raised concerns regarding the rejection of her health insurance claim by Aditya Birla Health Insurance.
According to the documents shared with us, the details of the policy and claim are as follows:
- Patient Name: Akansha Srivastava
- Member ID: PT31584851
- Policy Number: GHI-71-25-04530669-000
- Intimation Number: 1222585444509
Ms. Srivastava states that her claim for hospitalization related to Scar Endometriosis was rejected on the grounds that the condition was considered a maternity-related complication, which is not covered under the policy. The rejection communication also reportedly cited the 24-month waiting period applicable to Endometriosis.
However, the policyholder disputes this interpretation and has questioned both the medical and contractual basis of the decision.
Why the Policyholder Disagrees with the Rejection
In her representation, Ms. Srivastava has presented several reasons why she believes the claim deserves reconsideration.
Scar Endometriosis Is Not Maternity Treatment
According to her, Scar Endometriosis is a post-surgical medical condition that may develop after a previous surgery, including a Caesarean section, but the treatment itself is not maternity care.
She states that her hospitalization was not related to pregnancy, childbirth, delivery, or post-natal care, but was solely for the surgical treatment of a painful medical condition.
She argues that classifying the hospitalization as a maternity benefit is medically and factually incorrect.
Interpretation of the Waiting Period
The rejection reportedly refers to Clause D.1.2 – Specified Disease/Procedure Waiting Period (Code: Excl02).
According to the policyholder, the clause does not specifically mention that:
- Scar Endometriosis is treated as a maternity condition.
- Every hospitalization arising from Scar Endometriosis automatically falls under maternity exclusions.
- Post-surgical complications are excluded from coverage under the maternity provisions.
She further contends that applying the waiting period without considering the specific medical nature of her condition amounts to a blanket interpretation rather than an individualized assessment.
Policy Start Date Alone Should Not Decide the Claim
Ms. Srivastava acknowledges that her policy commenced on 26 July 2025. However, she argues that the policy inception date alone cannot justify claim rejection unless the insurer clearly demonstrates that the specific exclusion explicitly applies to the exact medical condition for which she was hospitalized.
Information Requested from the Insurance Company
According to the representation shared with Janta Ka Mudda, the policyholder has requested the following information from Aditya Birla Health Insurance, which she says has not yet been provided:
- The specific policy clause that categorizes Scar Endometriosis as a maternity-related condition.
- The medical opinion or expert assessment relied upon in concluding that the hospitalization was for maternity treatment.
- A copy of the complete claim assessment report and the basis on which the decision was made.
Why This Matters
Health insurance claim disputes often arise when policyholders and insurers interpret policy terms differently. Transparent communication, clear policy wording, and detailed claim assessments are important to ensure that customers understand the reasons behind claim decisions and can exercise their rights to seek clarification or appeal where appropriate.
Janta Ka Mudda’s Position
Janta Ka Mudda believes that every policyholder has the right to receive a transparent, reasoned, and evidence-based explanation when an insurance claim is rejected. Where genuine doubts exist regarding the interpretation of policy terms or the medical basis of a decision, insurers should provide complete clarity so that customers can make informed decisions about appeals or further remedies.
We respectfully urge Aditya Birla Health Insurance to review Ms. Akansha Srivastava’s representation, address the specific questions she has raised, and provide a detailed explanation supported by the relevant policy provisions and medical assessment. A transparent review will not only help resolve this individual case but also strengthen customer trust in the claims process.
Janta Ka Mudda will continue to support the policyholder by highlighting this issue until a fair and satisfactory response is received from the concerned insurance company. We also welcome Aditya Birla Health Insurance’s response, which we will publish in full in the interest of fairness and transparency.