[Resolved]  Bajaj Allianz General Insurance — BAJAJ ALLIANZ is deliberately misinterpreting the special condition

Address:

Nagpur, Maharashtra

Dear Sir
I would like to inform you all about the unfair practices of BAJAJ ALLAINZ for Claim settlement. BAJAJ ALLIANZ is deliberately misinterpreting the special condition to disallow the claim Amount Rs. 69330.

It refers to my Policy no. OG[protected]-[protected]Silver Health -Senior Citizen); my father (ASHOK SAKURE) and mother are covered for Rs. 3 Lacs each. I have purchased this policy in Dec 2010, and renewed every year before due date.
Medical test of my father and mother was also carried out by BAJAJ ALLIANZ in 2010 before issuing the policy documents.

During Feb 2013, my father observed breathing problem for 5-6 days, so he consulted doctor. After examination and required tests, doctor advised him to undergo Angioplasty (Heart related Surgery) without wasting time. So he has undergone Angioplasty on next day, in the hospital which is not in the network of BAJAJ ALLIANZ for cashless hospitalization.

We have submitted the claim (claim no is OC[protected]-[protected] for reimbursement of Amt Rs.235330/-
Bajaj Allianz has Approved Amt Rs.132000/- & Disallowed Amt Rs.103300/- ( Clarification by BAJAJ ALLIANZ as below)
1. Rs.100/- Registration charges not payable
2. Rs.900/- Bills not available hence deducted Rs.900/-
3. Rs.33000/- 20 % of co-payment Admission in Non Network Hospital
4. Rs.69330/- Maximum limit of indemnity is 50% of the sum insured)

We don't agree to point no. 4 ; deduction of Rs. 69330, under the special condition as motioned below.
This special condition is not applicable, because my father is not DIABETIC and the concern diseased in the claim (HEART related) was also not existing on or before commencement date of Policy - Medical check up was done by BAJAJ ALLIANZ before issuing policy document.

This Special condition is as below in the Policy Document -
Special Condition, If any : THIS POLICY EXCLUDES FOR ASHOK SAKURE ANY CLAIMS IN RESPECT OF ANY DISORDER, INJURY, DISEASE, DISABILITY OR TREATMENT WHETHER DIRECTLY OR INDIRECTLY CAUSED BY, OR ATTRIBUTABLE TO DIABETES/ALL LOCAL & SYSTEMIC COMPLICATIONS RELATED TO DIABETES INCLUDING BUT NOT LIMITED TO INFECTIONS, METABOLIC, VASCULAR ETC. DIRECTLY OR INDIRECTLY AND RELATED AILMENTS /ANY OTHER AILMENT EXISTING ON OR BEFORE THE COMMENCEMENT DATE. THIS EXCLUSIONSTANDS DELETED W.E.F 07-DEC-2011. IF THE POLICY IS CONTINUOUSLY RENEWED WITH US FOR THE NEXT YEAR .FROM SECOND YEAR ONWARDS THE MAXIMUM LIABILITY FOR THE ABOVE MENTIONED ALIMENT ITS COMPLICATIONS / DIS- ORDERS WOULD BE 50% OF LIMIT OF INDEMNITY PER POLICY PERIOD. (IN CASE OF BREAK IN THE RENEWAL THE BREAK IN CLAUSE WOULD BE STILL APPLICABLE)

BAJAJ ALLIANZ is deliberately misinterpreting the special condition to disallow the claim Amount Rs. 69330.

Vinay Sakure
+[protected]