Apollo Munich Health Insurance — Optima restore policy in the 5th year

Address:

Mumbai City, Maharashtra, 400050

Dear sir/madam,

I am in receipt of your letter dated 7th november 2016, terminating my health insurance policy, giving 30 days’ notice period and from the 30th day of the payment of the last premium.
We had opted for apollo munich, after a lot of convincing done your agent, without realising that we would have to face the present circumstances.
Our experience with your company this time around after having paid premium on time for four consecutive years and not having lodged any claim on account of virender raina for the past four years, since we did not need the same and when we actually needed it has been pathetic and as a customer and a cancer patient, i feel totally let down and cheated by your company. I say so because of the series of events that i had to go through which at each time showcased to me the unwillingness of your company to entertain any claim from me, probably because the amount in consideration was higher than the basic insured value. Let me enumerate the same for your ready reference:
• after the diagnosis and consultation with three specialist when each one of them was of the opinion that i needed to remove my left kidney immediately, after studying the policy documents and list of network hospitals, we decided on kokilaben dhirubhai ambani hospital & medical research institute, andheri west, mumbai for undergoing the operation.
• in view of the mandatory 7 day notice for pre-planned hospitalisation, as per the policy we considered the date of 7th of november and submitted all the requisite documents to the tpa desk on the 1st of november. [id: 295482/1 of virender raina]
• on 2nd the tpa received denial of cashless service and the reason given for the same was “cashless facility cannot be granted as presenting ailment for which treatment is sought comes under standard exclusion as per policy terms & conditions.”
• spoke to the helpline number asking for the clause number for understanding it better but they were unable to explain the same and then asked them to put me on to some senior person and finally was given the understanding that robotic surgery was not covered and that apollo munich did not have an mou in place for the same with the concerned hospital. [have recordings of the conversations had]
• the officer at the tpa desk also tried his best to understand the reason for denial but he was also given the same explanation.
• with understand that robotic surgery was not allowed, identified laparoscopic surgery for the same and with the help of a senior surgeon, and went to jaslok hospital and through their tpa desk applied once again [id: 296095/1] on the 4th of november. [ your letter mentions the date as 07/11/16]
• on the 4th itself an additional information request form was received with reasons “all past opd records related to kidney disease, investigation reports of the patient supporting the diagnosis, valid address proof copy of passport, ration card, aadhar card, telephone bill, electricity bill, not older than three months or current passbook with statement of bank account updated in the last 3 months with latest photo of the patient.” tpa replied at 5.07 pm on the same day.
• on the 4th itself another additional information request form was sent by you to the tpa with the reasons “1) latest photo of the patient 2) all previosu treatment records and investigation reprots related to chronic colitis since 2011.” [note the typo is as per the letter received]. The tpa informed us at 7.37 pm on the same day and we went with the documents and met them on the 5th morning. Tpa replied at 9 am on 5/11/16.
• on the 5th we once again receive denial of cashless service with the reasons: cashless facility cannot be granted due to non-disclosure of material facts which are observed in the documents provided during the current hospitalization. However member can go for reimbursement with all previous insurance and medical records. It can be processed as per merits of the case.”
• thereafter we receive a letter dated 7th november as mentioned above as notice for termination.

My contention at this juncture:
1. Before the issuance of the policy there was a completed medical check up done and at that point had informed your appointed medical practitioner of my entire medical history including the colon ailment of 2011. He had made a note of the same in his records which were to be submitted to you, confidentially. You may refer to the same and verify the statement.
2. Additional 10% premium was already loaded on the policy before the commencement of the policy.
3. As per the policy any pre-existing diseases/conditions are covered after a waiting period of 3 years [36 months]. The first premium was paid on 27/02/2012. The policy document was issued on 28/03/2012 and began coverage from 00:00 hrs of 28th. The claim was submitted in november 2016 – 54 months – well beyond the period.
4. I have a certificate from a senior medical practitioner which clearly states that the kidney disease is not even remotely connected to the colon infection of 2011, what so ever.
5. The ground of cancellation is unjustified and illegal.
Our humble request is to reinstate the policy with immediate effect.
Meanwhile, we are submitting the claim in the requisite format through registered post/courier service.
We request for an early communication and redressal of our grievances.

Regards,

Virender raina