My health insurance claim experience with HDFC Ergo General Insurance

This is an unrelated post but might help some.

Recently my father suffered from a sudden heart attack. We immediately rushed to the hospital and I was asked for insurance details. I submitted all the documents that were asked and the hospital filed a cashless claim for the treatment. Note that this was a listed network hospital. Angioplasty was done in the right artery and a stent was placed to open up the blockage.
24 hours passed and I got a rejection email from HDFC ergo saying that
"As per the available documents, Possibility of the present ailment being Pre-Existing (as per policy terms & conditions) could not be ruled out
i.e.CAD has possibility of being pre-existing from the inception of the policy. hence cashless approval would not be possible at this juncture."

For the record, my father didn't have any pre existing disease or co-morbidity related or unrelated to any cardiac ailment or medication. The denial was unjust and unfair. I tried to escalate it to their grievances redressal but they said it's their final stand and nothing can be done. However they can reconsider my claim on reimbursement basis. I had to pay for the treatment from my pocket even after paying premium for years and promise of "100% cashless claim settlement."
My dad got discharged, post which I filed a reimbursement claim.They sent a verification agent at my house who cross verified all the details and collected all relevant documents and information. As per IRDAI guidelines, a claim should be settled within 30 days from the date of last document collected.
A month passed by, I waited patiently, tracking my claim status on their website which said "Claim Under Process". On 29th October 2024 at 11:30pm, I received an email from them asking for past treatment records and consultation papers for the admitting ailment. Since my father was devoid of any pre existing disease, there was no "record" or "consultation paper" available for the ailment.
Interesting thing is, all this information was thoroughly verified during claim filing process, multiple times. I even attached a note from my family doctor stating that the patient has no history of cardiac illness or any medication. Now just when the claim was supposed to be settled, they asked for documents that don't even exist. It was obviously a way to delay the claim settlement process.
I wrote a strong worded letter to their grievances redressal team quoting rules by IRDAI about pre existing disease and how the current ailment falls out of scope and claim settlement timeline of 30 days. To my surprise, this got them on track and my claim was approved today morning at 12 noon.

Some Observations:
I felt like their whole claim settlement process was sort of AI driven and it was very difficult to get in touch with a human. Their customer care is pretty dumb and they have no idea how things work. As soon as I threatened them with legal escalations via email, they quickly approved my claim. I also wrote a thread about this incident on twitter, that helped too.
I feel like if one's case is genuine and all the pre-existing diseases and Lifestyle declarations(smoking and drinking) are done properly, there is absolutely no way HDFC Ergo can deny the claim as they too have to adhere to guidelines set by IRDAI. Yes they did delay the whole process with their so called "queries" and "additional information required" but got on track eventually when they realised I am not gonna back off.

This whole process added a lot of unnecessary stress and anxiety to my whole family. I feel if the process should be more transparent and insurance companies should honour legit claims on time. I do give them a benefit of doubt as there are a lot of fraud cases too.

Tips:
A few things I learnt from the whole process:
1. If your case is genuine and you've declared everything properly, you should fight to get your money back. Follow the escalation matrix and don't hesitate to threaten them with legal escalations. Also, quote rules from IRDAI along with the links in your emails. It does fast track the whole process.
2. Avoid talking to their customer care. They are dumb. Converse over email, it is a solid written proof of everything.
3. Since I bought the policy directly, I had no one to reach out to. A lot of people suggested me that if I would have bought it through an agent, they would have helped me in claim settlement. Idk how true is that, in my experience all sales people just care about their commissions.
4. The whole process might take some time but you will get your money if your case is genuine with no red flags.