Insurance Claim Denied in Varanasi? UP Eastern Region Appeal Guide

Varanasi — one of the world's oldest continuously inhabited cities — is also eastern Uttar Pradesh's most significant healthcare hub. The Institute of Medical Sciences, Banaras Hindu University (IMS-BHU) is a major academic medical centre drawing patients from across eastern UP, Bihar, and Jharkhand. Heritage Hospital, Shubh Hospital, and Sunrise Hospital provide private care.

For many patients and families who travel to Varanasi for serious treatment, an insurance claim denial on top of an already stressful situation can be devastating. Here is how to fight back.

Why Claims Are Denied in Varanasi

• IMS-BHU documentation complexity: As a government academic medical centre, IMS-BHU has multiple departments, each with separate billing and recording. Assembling a complete claim package requires careful collection of receipts and records from each department.
• PED exclusions on rural populations: Patients from rural eastern UP, many of whom are first-time insurance policyholders, face PED exclusions for conditions like diabetes, anemia, and respiratory disease that were never formally diagnosed before.
• Low network density in eastern UP: Many private facilities in Varanasi city and surrounding districts of Jaunpur, Ghazipur, Mirzapur, and Chandauli are not on private insurer networks.
• Religious pilgrimage-related emergency claims: Varanasi receives millions of religious pilgrims annually. Emergency treatment during pilgrimage may be covered, but insurers sometimes dispute "temporary" presence in the city.
• PMJAY procedure mismatch: Pre-authorization under Ayushman Bharat may be denied if the procedure code entered by the hospital doesn't exactly match the HBP listing, even if the treatment is substantively covered.

Step 1: Internal Grievance

Write to your insurer's Grievance Redressal Officer within 30 days of denial. Insurers operating in eastern UP include New India Assurance, Star Health, United India, National Insurance, and Niva Bupa.

Your letter must:

• Quote the specific denial clause and challenge it with evidence
• Include a treating doctor's certificate with ICD-10 codes
• Attach complete discharge summary, bills, and investigation reports

The insurer must respond within 15 days per IRDAI rules.

Step 2: IRDAI IGMS

File at igms.irda.gov.in for regulatory escalation. IGMS complaints create a formal national record.

Step 3: Lucknow Insurance Ombudsman (Covers All Uttar Pradesh)

Varanasi falls under the Lucknow Insurance Ombudsman's jurisdiction.

Office: Insurance Ombudsman, Jeevan Bhawan, Phase-2, 6th Floor, Nawal Kishore Road, Hazratganj, Lucknow – 226 001.

Filing is free, no lawyer required, awards up to ₹30 lakh. File within one year of the insurer's final rejection.

IMS-BHU Claims: Practical Documentation Guide

IMS-BHU is one of India's oldest and largest government medical universities, with dozens of clinical departments. For a successful reimbursement claim:

1. OPD records: Collect the OPD card and all prescription slips from the first consultation
2. Admission records: Obtain the admission slip or IPD registration document
3. Department receipts: Each department (surgery, medicine, radiology, pathology, physiotherapy) issues separate receipts — collect them all
4. Consolidated bill: Request a final consolidated bill from the main billing section with the official BHU/IMS stamp
5. Discharge summary: Ensure it contains the treating consultant's name, registration number, diagnosis with ICD codes, treatment given, and follow-up instructions
6. Operation notes: For surgical procedures, private insurers may request operative notes — the medical records department can provide a certified copy

PM-JAY Eastern UP and Varanasi

Varanasi district has a large Ayushman Bharat beneficiary base. For PMJAY denials in Varanasi:

• Contact the Varanasi district PM-JAY helpline or dial 14555
• If IMS-BHU is the treating hospital and is empanelled under PMJAY, the hospital cannot deny treatment for listed HBP procedures
• The UP State Health Agency has a grievance portal for escalating PMJAY denial complaints
• Mukhyamantri Jan Arogya Abhiyan (state extension) covers additional categories — ensure your family is registered under both schemes

Pilgrims and Out-of-State Patients

Varanasi regularly treats patients from Bihar, Jharkhand, West Bengal, and Madhya Pradesh who travel here for religious or medical reasons. If you are an out-of-state patient:

• Your home state insurance policy covers treatment across India — there are no geographic restrictions in standard private policies
• For PMJAY, you can use your Golden Card at empanelled hospitals in Varanasi regardless of your home state
• Emergency treatment at any hospital — network or non-network — is claimable under reimbursement

Fight Back With ClaimBack

Whether you are a local resident or travelled to Varanasi for treatment, your insurance rights are fully enforceable. ClaimBack helps you assemble and submit a compelling appeal.

Start your appeal with ClaimBack

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity in Insurance Claims?
• India Insurance Ombudsman Guide