[Resolved]  National Insurance Company — Harrsment to get medical services under cashless policy

Address:

Uttar Pradesh

Dear Sir,
Greetings of the day!!!
My Mother, Mrs. Neelam Bakshi, is enjoying the insurance cover from Oriental Insurance as per details under mentioned:-
Year Policy Number Assured Amount
08-09 222200/48/2009/140 Rs.2,00,000/-
09-10 222200/48/2009/161 Rs.3,00,000/- 10-11 222200/48/2009/233 Rs.3,00,000/- 11-12 222200/48/2009/134 Rs.3,50,000/- 12-13 222200/48/2009/399 Rs.3,50,000/-
She was admitted in Regency Hospital on 24/12/12 for the Total Knee Replacement, with the due information to the TPA (E Meditek). The pre approval of the claim was approx 3,30,000/-, as informed to us by the hospital. Later after 2-3 days the hospital informed us that the TPA has approved Rs.2,00,000/- only with the comment of Limit Exhaust.
Upon calling the TPA, we were informed the amount of the claim will only be as per the sum assured 4 years ago, and according to them it is from 08-09, i.e. policy number 222200/48/2009/140.
We had taken up the issue with the Insurance company and the TPA and after 4-5 follow ups, they had informed us that they will only accept the claim of Rs.2,00,000/- as per there clause, which is under mentioned:-
QUOTE (MESSAGE FROM TPA)
8 RENEWAL OF POLICY:
a) The Company shall not be responsible or liable for non-renewal of policy due to non-receipt or delayed receipt (i.e. After the due date) of the proposal form or of the medical practitioners report wherever required or due to any other reason whatsoever.
b) Notwithstanding this, however, the decision to accept or reject for coverage any person upon renewal of this insurance shall rest solely with the Company. The company may at its discretion revise the premium rates and / or the terms & condition of the policy every year upon renewal thereof. Renewal of this policy is not automatic; premium due must be paid by the proposer to the company before the due date.
c) The Company normally sends renewal notice but not sending it will not tantamount to deficiency in services.
If the policy is to be renewed for enhanced sum insured then the restrictions as applicable to a fresh policy (condition 4.1, 4.2 & 4.3 will apply to additional sum insured) as if a separate policy has been issued for the difference, subject to medical check up as per norms of the Company. The cost of Medical check up shall be borne by the insured.
UNQUOTE (MESSAGE FROM TPA)
Sir, I would like to put here that no such clause was informed to us at the time of the limit enhancement by the Agent or the by the insurance company. I am attaching the policy cover note along with, in which there is no such condition mentioned that what would be the upper cap to the claim amount in case of need.
From last 3 years, we are paying the premium on the sum assured of Rs.3,50,000/- and when there is the need, the insurance company is running from their responsibility by taking the excuse of the hidden clause.
Please look in to the same because we belong to a middle class family and had already spent around Rs.2,00,000/- additional on the treatment of my mother, apart from the claim amount. I would request you to consider the case on the top priority and guide us further.
With Warm Regards,
Amit Bakshi
+[protected]