[Resolved]  Sanjay Arora — COMPLAINT AGAINST MEDICLAIM

Address:

East Delhi, Delhi

Respected Sir/ Madam,



This is to inform that I am Sanjay Arora residence of B-31, East Krishna Nagar, Delhi 110051 had applied for the mediclaim policy of my parents named Mr Ranjha Ram Arora ( Age : 63 ) and My Mother Named Mrs Mohan Devi Arora ( Age : 58 ) dated 27 May 2008 of year 2008 under the policy number 350204/34/08/87/00000273. at the initial stage of the formalities of the mediclaim policy, company had demanded for the medical reports of my parents, which had been completed in the year 2008 by our side ( Reports submitted in the company with the mediclaim application). In the year from May 2008 to May 2009 there is not any claim arise in the policy.

In the next year of month May 2009 we had renewed the policy under the policy number 323500/34/09/87/00000431 dated 27 May 2009 under the continuation of previous policy. But unfortunately in the month of September dated 3rd my mother complained about the pain in the chest and she got unconscious in the midnight around two ‘o’clock. We take her to our near by reputed hospital Max Balaji Hospital in Patparganj instantly. There they admitted the patient i.e. my mother and start processing for the relief. There they told us that the patient had suffered by minor attack and they recommend us for the CABG Surgery.

We told them that we are having a mediclaim policy by New India Assurance Company Ltd., therefore no such complication arises and cashless facility will be entertained. As the hospital individuals send the claim and details of the treatment to the TPA of New India Assurance Co. Ltd.( i.e. Safe ways Medical Services Pvt Ltd.) But at the initial stage the TPA Safeway’s mediclaim services pvt limited had refused for the cashless facility but ensure us that the claim will be settle down under reimbursement process. Also the same has been downloaded by my agent to me. We don’t mind and process the treatment there and paid all my bills there itself. My mother get discharge by completing the treatment of CABG surgery dated 07 September 2009.( My Mother get admitted for complete 5 days in Max Balaji Hospital)

After paying an amount of Rupees Two Lakh sixty thousand eight hundred twenty three rupees and sixty nine paise (2,60,823.69) we get discharged my mother. As we are not financially strong therefore we had to get the arrangement of money by the market on higher interest rates. After getting discharged my mother, I again contacted my agent Mr Lalit about the reimbursement process. He assures us that our claim will be settled 100% and all the money which I had paid to the hospital will be reimburse as soon as possible. I had submitted all the original bills and all investigation reports in original to the company by the hands of Mr Lalit. After submitting all the documents and completing all the formalities Mr Lalit again assure us that our claim will be settle immediately as soon as possible. He assures us that he will be going to contact us with the claim amount within a month.

After waiting for a long more than a month, when Mr Lalit had not contacted to us we again remind them about the claim. But he replied that our claim is under the process and will be settle down on urgent basis.

Again and again we contacted to the TPA for the status of my claim but we didn’t get any satisfactory answer from both of them. Both of them try us to make a fool o[censored]s. Whenever I talk to my agent he replies that the claim is under process and it will take some time. And the TPA replies many time that sometime that “Mr X official is on leave and we had discussed the case with Mr X doctor and my claim will be done”.

After the period of nine months of the claim arise, the TPA asked me to resubmit all the documents as an accident occur in the Kirti Nagar office in which the complete file had been damaged and get fired but I think it’s a fake fire so kindly investigate the reason of fire. There also they assure us about the claim. We again submitted all the documents to the TPA.

In between my policy get renewed by the same agent and by the same TPA on very high premiums dated 27 May 2010 under policy number 121300/48/2011/2842 of amount approx 18,000.00 instead of 11,000.00.

At last after getting so much annoyed for not getting any reply from both of them I try to mail directly to the TPA from the month of July 2010 dated 15 .But still at that moment I had belief that my claim will be entertained because the claim is genuine.

After mailing chain mails to the TPA, I was totally surprised by the answer of the TPA that my claim had been rejected because hypertension is not covered for the first two years of the policy.

I again asked to the my agent but this time he also refused the same. Even I get the assurance by the TPA officials and by my agent that my claim will be entertained. But today both of them refuse the same. I was really shocked.



I would like to know that as we had submitted all the medical investigation reports in the initial time of taking the mediclaim policy. At that time my mother does not have any compliant of Blood pressure. Also the reports had been submitted. Also if company had decided to cover my parents than why today they are making fool o[censored]s. They should not entertain such kind of applications in which the probability of claim are little higher than normal common man of age 30-40.

Now today I lost my believes, and approach to your justice that why my claim is not being entertaining? And why my claim status had not being updated to me on time. Why it take to decline claim after 10 months?

Here I would like to draw your kind attention towards the TPA where I demanded for all the bills and investigation reports return back so that I will go legally against them, than they refuse to give me back stating that all the files in Kirti Nagar office get fired due to which my complete file is missing. This statement is given by TPA official Mr. Gurpreet Singh in Kirti Nagar office. As I am not agree with the statement.

Today I approach your door because I am helpless today. On the one side I am unable to pay the money which I had taken from the market on higher interest and on the other side the company had decline the claim. What should I do now? Where should I go for justice?



So please look into the matter and suggest any solution for the case. Trust me I will go the last extent for this claim because I am unable to pay the amount.


no body listen us even the comany & ombudsman, ihad mailed many times both ombudsman & New india asurance comany no body listen us only one call recieved by me of mr Alok of new india asurance comany.



Thanking You,



Yours truly,



Sanjay Arora,

S/o Sh Ranjha Ram Arora

R/o B-31 East Krishna Nagar,

Delhi 110051

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