Oriental Insurance Company — Bima Lokpal Complaint for unsettled partial claim reimbursement in Health Insurance of Oriental Insurance Company

Dear Sir /Madam,

I am writing this letter to you to grab your attention to the unsettled partial claim reimbursement of my health insurance claim. so requesting you to can you please help me to approve my unsettled claim from Oriental Insurance company.

Claim details
TPA Claim No. : MDI6709673

The overall summary is that my mother was admitted in hospital during 15th Nov to 18th Nov 2021. and Final bill generated with amount 309883/- Then Initially claim approved only for Rs. 226609.

After that, I have raised complaint to regional office of Oriental Insurance company so they have approved few more additional amount Rs. 20196.
So here my concern is that If I have not raised any complaint or not putting my claim file in reconsideration so in that case I have been directly lost Rs. 20196/- which was valid claim for reimbursement amount. so honestly I don't know how to deal with insurance company to approve unsettled claim so Kindly help me on the same.

And still they are not ready to approve on unsettled claim (2 items which is listed below) with saying that "We have process the claim as per PPN Package with below detailed reasons" even I have asked queries to clarify the reason o[censored]nsettled amount with proof or evidence but they are saying every time only one line "As per PPN Package".

1. Rs-9000/-As per PPN pacemaker implantation max payable Rs 47000/-
2. Rs-10000/-As Per PPN -second surgery angiography payable 50% .

So, my concern here is that As a policy holder, I bought one health policy so I would be expecting that claim to be processed as per policy norms/terms as there is no clause mentioned for PPN Package in any policy which is received every year.

Thanks
Maulin Desai
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