[Resolved]  Mediclaim — Rejection of claim Hospitalisation Claim No. 1905763 under SENIOR CITIZEN Policy No. 040700/48/10/97/00003863 of Mrs. Naresh Sethi

Address:

North East Delhi, Delhi

The Divisional Manager,
United India Insurance Co. Ltd.,
Divisional office No. 7, Jamna House, 3rd floor,
Padam Singh Road, Karol Bagh,
New Delhi-110005.

Reg: Hospitalisation Claim No. 1905763 under SENIOR CITIZEN Policy No. 040700/48/10/97/00003863 of Mrs. Naresh Sethi.

Dear Sir,

A Hospitalisation Claim for Rs.49065.00 for having incurred expenses towards CATARACT
Surgery from Sardana Eye Institute was submitted to the MEDI ASSIST INDIA TPA PVT. LTD
complete in all respects on 29.3.2011 as per their receipt marked C -32.

On 4.4.2011 a SMS was sent by LM-MA on my mobile no [protected] which read as “ Clm no 19 05763 Received on 4.4.2011 (actually received by them on 29th March) is denied . Please refer to
Repudiation Letter” but no such reference letter was received by me.

However, when asked about the reasons of denial of the above claim, we were told to contact your
Office. We, accordingly, after repeated telephonic talks / visits at your office and after coming to know about the reasons of denial of the above claim, the Senior Executive Mr.P K Arora of the above office got a letter issued on 21.6.2011 to the MEDI ASSIST INDIA TPA PVT. LTD reiterating therein the contents of their earlier letter enclosed/submitted along with the claim papers that the above-said Policy is running without break as per details given below:

260300/46/06/8500000/97 NATIONAL INS CO LTD wef 12.3.2007 to 11.3.2008
221600/48/07/41/00003531 U I I CO LTD wef 12.3.2008 to 11.3.2009
221600/48/09/41/00000328 U I I CO LTD wef 12.3.2009 to 11.3.2010
Q 00009141 Bharti A XA Gen Ins Co Ltd wef 12.3.2010 to 11.3. 2011

The above letter dated 21.6.2011 issued by UII Co. Ltd. addressed to the MEDI ASSIST INDIA TPA PVT. LTD was handed over in person to them on 21.6.2011 duly acknowledged by them.

To my utter surprise, I am quite pained to write to you that the above TPA , vide their UNSIGNED letter Dated 4th July, 2011, have again informed me that the claim is repudiated as per policy term & Conditions and have not accepted the continuity of the above policy despite having confirmed by UII Co.Ltd as per your letter dated 21.6.2011,a copy of which has been endorsed by them to your office.

However, we, for the sake of your convenience reproduce below the contents of their letter dated 4.7.2011 addressed to me and copy sent to your office:

“The undersigned has gone through this claim file in detail. This claim pertains to Naresh Sethi covered under SENIOR CITIZEN MEDICARE POLICY for the expenses incurred in the Sardana Eye Institute. As per terms and conditions of the Insurance Policy expenses related to cataract is not payable for first two years of policy inception. Hence, under exclusion clause 4.3 o[censored]IIC, this states that the continuity of policy from UIIC only is necessary for minimum of three years. Hence, this claim is repudiated as per policy term & conditions.

In case you further facts or information to substantiate in this claim, please forward the same to us.”

From the above, it gives me an impression that I am being befooled/misguided either by
UNITED INDIA INSURANCE CO. LTD or by the TPA MEDI ASSIST PVT.LTD. The very purpose of confirming the continuity clause of the policy by the parent Co. who issued the policy and then issued a letter stating that this policy is insured with Divisional Office N0 7 since 4th years WITHOUT BREAK (enclosed and marked page no.3 with the claim documents) and confirmed again the said contents about the continuity vide UIIC Letter dated 21.6.2011 gets defeated, which is a clear case of BETRAYAL. It is a clear cut case of wilful denial of the claim by way of misinterpretation/twisting of facts as per convenience by TPA.

It would have been in the fitness of things if the TPA Medi Assist PVT. LTD, before denial of the claim, would have taken up the matter with you in the light of the facts that the reason given by them for denial of the claim is in total contravention of the facts given by UIIC, in terms of which the above claim is payable as per rules and in no way the above claim can be denied to me as at the time of renewal of policy I was assured that I am eligible/entitled to the claim as such for the cataract surgery.

Kindly take up the matter with the concerned TPA and get the claim passed without any further loss of time as the issue of payment of claim has already been delayed considerably else I will be constrained to adopt another course of action.

We are endorsing a copy of this letter to Medi Assist India TPA PV T. LTD for their reconsideration of the matter in the light of the above facts.

Thanking you,

Yours faithfully,


(Mrs. Naresh Sethi)