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[Resolved]  Family Medicalim Policy From New India Assurance Co. Ltd. — Illegal Repudiation of Claim By TPA

With due respect I beg your permission to represent my query about a hernia claim. I am a Mediclaim Policy Holder (family mediclaim) of New India Assurance Co. Ltd. since 1999. My present policy no. is 510603/34/08/11/00003494. My Service Branch is 39,Diamond Harbour Road,West Bengal,Kolkata- 700 008. Thakurpukur Branch (510603). In the year 2002 my wife gave birth to a baby and it was a caesarean baby. In the year 2003 I included my wife in my policy.
In the year 2008 in the month of September I consulted a Doctor for my wife with symptoms of bulging belly. After formal check-up we came to know that she has developed a hernia and it has to be operated. Accordingly she got operated for Incisional Hernia on 08/12/2008.
After the operation I submitted a claim with all relevant documents to the TPA E-Meditek Solutions in January 2009. In March 2009 TPA informed me by a letter that my claim is repudiated as per exclusion clause 4.12 of Mediclaim Policy 2007. In May 2009 I re-appealed to my branch vide letter dated 06/05/2009 to reconsider my case. But unfortunately till date there is no response from the branch. The activity of the Branch manager and DO seems to be more of self-defending. Their attitude seems to be very mysterious because each and everytime I call them up they inform me you are supposed to get this claim but we have to find out why the TPA is not giving it.
Under this circumstances I find no other way other than seeking your kind help in this matter. I have a simple question "Am I entitled to get this claim, when this is her first claim from the time she has been included in the policy". Secondly "What is the extend of responsibility of your service branch, only collect premiums or help the customer also when they are being harassed by the TPA."
Awaiting your kind reply
Complaint marked as Resolved Aug 14, 2020
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