[Resolved]  General Insurance — Mediclaim is not reimburse

Address:

Aligarh, Uttar Pradesh

Submitted by: Nirendra Sharma S/O Shri Shankar lal Sharma
Category: Insurance Policy
Complaint against: Reliance General Insurance Co. Ltd.and Paramount Health Services (TPA) Pvt.Ltd.
Complaint Number: 12064378,[protected]In Grievance Redressal Cell, Reliance General Insurance Co. Ltd.)

IRDA Complaint no[protected]
Amount loss/claim: Rs. 108000.00
Topics: Mediclaim from Reliance General Insurance Co. Ltd
Sir/Madam
With due respect, I would like to draw your kind attention to my following grievances which caused a great mental tension to me as well as financial harassment also.
Sir, I had taken a mediclaim policy provided by Reliance General Insurance Company for my Father and Mother since last 5 year (2008).M/S paramount is TPA & Insurance co. is Reliance Gen. Insurance.
Policy is renewed every year .For this year policy is valid up to 04/06/13 & insurance cover is Rs.200000/-
Firstly i go for cashless procedure, as per policy procedure I have pre-intimated TPA before hospitalization on 22.09.2012 and i have Authorized latter on 26.09.2012
My Father was admitted for 3 days (28.09.2012 to 01.10.2012) at Gangaram Hospital -New Delhi.
After operation Gangaram Hospital sanded all documents including i.e. Bill, Discharge summary etc...To TPA on 01.10.2012. After some time I received a call for denial because of some Existing Problem (Multiple Myeloma)...I have claimed re-reimbursement first time for my Father for ERCP and Operation of Gall Stone in the month of 04 Oct 2012.
Then I go for reimbursement for my Father of above claimed on 04/10/12.i went to Paramount TPA/Reliance General Insurance company Okhla Office and Submitted all the original Document for Gangaram Paper with Multiple Myeloma Document (All Reports) from since 2008.
Then I received deficiency letter from TPA on 16.10.2012. In response to that letter again I send a mail to TPA on 18.10.2012.
I didn’t reimbursement anything regarding Multiple myeloma since 2008 now..i have submitted the reimbursement regarding acute Calculas cholecystits(Gall Stone operation with ERCP)..
I already submitted the Certificate of Gangaram Hospital written by Both Doctors..

1- Certificate of Dr Anil Arora done ERCP and Gall stone Operation.
2- Certificate of Dr Shyam Agrawal taking Medicine regarding Multiple Myeloma since 2008.

The latter said that there is no relation about Multiple myeloma and Gall Store Operation...this is Entire different illness......

After this process TPA/Reliance General Insurance company has rejected the claim stating that this claim is not admissible as per the terms & condition of the policy.

This is mail i received from reliance on 28 Nov 2012...
On perusal of claim documents, Claimant Mr. Shankar Lal Sharma was hospitalized from 28/09/2012 to 1/10/2012 as a case of gallbladder and CBD stone for surgical management. Claimant is covered under Reliance Health wise Standard policy from 4/06/2008. Patient is a known case of multiple myeloma from May 2008 and has history of haemarrhoidectomy in 2004. The same is not declared in proposal form. As per policy terms and condition 2; duty of disclosure- The policy shall be null and void and no benefit shall be payable in the event o[censored]ntrue or incorrect statements, misrepresentation, misdescription or non-disclosure of any material particulars in the proposal form, personal statement, declaration and connected documents, or any material information having been withheld. We regret our inability to admit this liability under the present policy conditions. We also reserve the right to repudiate the claim under any other ground/s available to us subsequently.

In view of above ,I feel that if above treatment was excluded from policy ,Also note that in policy cover is mentioned that pre Existing Disease is cover after 4th yr renewal .
I would be happier if I didn't want to claim & it’s not a earning business.
This is harassment to the customer at the time of their need by the Reliance General insurance co. And it’s service provider. Therefore you are requested to go through that Matter and arrange to provide me justice by paying the full medical expenses as claimed & with a lesson to company --- not to harass public on flimsy ground especially when the customers are in problem.
After that he is not returns the Original document at all in all the condition and he wants in written (Affidavit) that we don’t take any judicial action against him.
Amount lost by me is much more (rs.108000/-) & It’s a totally cheating by TPA/ for rejecting claim giving that reason.
Pl.Log the complaint & give me justice.

Regards
nirendra sharma
S/o Shankar lal sharma
My policy no is [protected]
Shankar lal Sharma
[protected]@yahoo.com
[protected]