Oriental Insurance Company — Claim Intimation 12149 Happy Family Floater Medical Insurance Policy No. 131200/48/2015/7749

Address:

Mumbai City, Maharashtra

Dear Sir / Madam, This is in reference to above subject claim settled on 20th Feb 15 through Dena Bank with an Amount of Rs. 35000 against the claim amount of Rs. 50863 which is short amount by Rs. 15863. I wish to bring your attention as below : ( 1 ) Up on renewal of my Policy I have been given 3 Pages Renewed Policy and where in no clear conditions with specified subject treatment and claimable amount for the same treatment. ( 2 ) Even in my intimation to GHPL to register my claim prior to operation, I have mentioned the package of Rs. 50000 for Left Eye Cataract operation would be charged and the claim of same amount will be filed to ORIENTAL Insurance. In reply, I received only a claim form and no alert to notify me about the charges will be settled for the same . ( 3 ) I had under gone operation in August 2011 for Right Eye Cataract Operation with same Doctor in Same Hospital under Rs. 50000 Package and your office had settled with the full value. Up on my approaching to Oriental Insurance Borivali Branch with guidance of Mr. Nawal Singh Oriental Head Office, I have been replied that Reasonable & Necessary Expenses claimable which are pre agreed by Net work Hospital & TPA will be approved for claim. This information is remain with in record of TPA and Oriental Office, The specific amount is neither given with policy conditions nor is informed during our intimation reply even after my declaration during the intimation of my wish to go for operation. The information regarding Reasonable & Necessary Expenses pre agreed by Net work Hospital & TPA kept silent with in the respective their own offices and not informed to Policy Holder so that every time they can dispute the claim and settle with short payment with declaring under Reasonable & Necessary Expenses, which is quite obvious. It is shocking to me that the amount is deducted with no fault of mine starting from handing over to me with Renewed policy in which no declaration of current deductions in our claim bill plus no alert from GHPL in spite of my prior intimation during registration of claim. I have taken the Medical Insurance Policy with a maximum claimable amount of Rs. 6 Lacs and for the betterment of my Health with proper medication plus to avoid any re occur the same difficulty. I have spent money Rs. 50863 for my operation which adds medicines bill prescribe to me and would like to request you trusting that you would assist me for the reimbursement of balance amount of my claim at the earliest. Thanking you, Yours Sincerely, Hemant Panchal B206, Borivali Adinath Apt., Saibaba Nagar, Borivali West Mumbai 400092 Mob.No. 91 [protected]