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[Resolved]  New India Assurance Mediclaim Policy — Misinformation and non payment of claim

My sister Ms Priya Taneja has a cashless medical policy from New India Assurance Company Ltd (policy number 310600/34/09/11/[protected],

Recently my sister was admitted to Artemis Hospital Gurgaon for treatment
She was admitted to the hospital on 11th June 2009 for treatment. The procedure was a surgery in OT and post drainage of wound.

The sum assured on the policy in Rs 100000/- and it is cashless in nature.

According to the policy my sister was entitled for a room not exceeding 1% of the sum assured which was Rs 1000. We upgraded the economy room from 4 in a room to twin sharing which was being charged at Rs 2450/- per day with a promise to the hospital to pay the remaining amount.

The hospital staff at this point informed me that the charges for doctor visit and others will also change according to room type, which I agreed upon and I will have to pay just the difference in the amount of charges entitled and actual charges being made.

At the time of discharge on 14th June 2009 the hospital informed me that according to the policy I will have to pay 60% of the outstanding amount. After two hours of arguments and discussions with the TPA department Raksha I had to pay 60% of the bill payable even though my policy is complete cashless and the bill was only for Rs 45615/- while sum assured stands at Rs 100000/-.

When spoken to the TPA people they gave me some calculation and did not share with me a figure which will be given to the hospital. They asked me to read the regulations of the policy.

Henceforth the policy document only reads as follows:

Following reasonable, customary and necessary expenses are reimbursable under the policy:
1. Room boarding and nursing expenses as provided by the hospital/nursing home not exceeding 1.0% of the sum insured (excluding cumulative bonus) per day or actual amount, whichever is less
2. ICU.ICCU expenses not exceeding 2.0% of the sum insured per day. Or actual amount, whichever is less
3. Surgeon Anesthetist, medical practitioner, consultants specialist fees
4. Anesthesia, Blood oxygen, operation theater charges, surgical appliances, medicines and drugs, chemotherapy, radiotherapy, artificial limbs ….. and other medical expenses related to the treatment,
5. Pre hospitalization medical charges up to 30 days period immediately before the insured’s admission to the hospital for that illness or injury
6. Post hospitalization medical charges up to 30 days period immediately after the insured’s discharge from the hospital for that illness or injury

Note:

The amounts payable under 3 and 4 shall be at the rate applicable to the entitled room category. Incase insured opts for room wit higher rent than the entitled category as under 1, the charges applicable under 3 and 4 shall be limited to the charges applicable to entitled category.



The Complaint:

The above part claims nowhere that the amount, which will be reimbursed, will be according to some percentage between the entitlement and actual expenses made on room rent acquired by us. New India Assurance has misled me as nowhere the policy it is mentioned about the above and neither the agent who sold me this informed me of this complexity.

I was made to pay 60% of the bill of Rs 45615/- (excluding medicines expenses) for which I had to pay nothing.

I would like to take this up for serious action as many consumers like me may be duped into this with no clarity on what the policy offers to the insured. Ideally I should have been just paying the difference in the room rent plus the difference of charges for OT and visiting doctors as applicable to the room rented.

A copy of the above complaint has been submitted to the Grievance Cell of New India Assurance
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Aug 14, 2020
Complaint marked as Resolved 
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New India Assurance Mediclaim Policy — Non Payment of Claim and misinformation

My sister has a cashless medical policy from New India Assurance Company Ltd (policy number 310600/34/09/11/[protected]

Recently my sister was admitted to Artemis Hospital Gurgaon for treatment
She was admitted to the hospital on 11th June 2009 for treatment. The procedure was a surgery in OT and post drainage of wound.

The sum assured on the policy in Rs 100000/- and it is cashless in nature.

According to the policy my sister was entitled for a room not exceeding 1% of the sum assured which was Rs 1000. We upgraded the economy room from 4 in a room to twin sharing which was being charged at Rs 2450/- per day with a promise to the hospital to pay the remaining amount.

The hospital staff at this point informed me that the charges for doctor visit and others will also change according to room type, which I agreed upon and I will have to pay just the difference in the amount of charges entitled and actual charges being made.

At the time of discharge on 14th June 2009 the hospital informed me that according to the policy I will have to pay 60% of the outstanding amount. After two hours of arguments and discussions with the TPA department Raksha I had to pay 60% of the bill payable even though my policy is complete cashless and the bill was only for Rs 45615/- while sum assured stands at Rs 100000/-.

When spoken to the TPA people they gave me some calculation and did not share with me a figure which will be given to the hospital. They asked me to read the regulations of the policy.

Henceforth the policy document only reads as follows:

Following reasonable, customary and necessary expenses are reimbursable under the policy:
1. Room boarding and nursing expenses as provided by the hospital/nursing home not exceeding 1.0% of the sum insured (excluding cumulative bonus) per day or actual amount, whichever is less
2. ICU.ICCU expenses not exceeding 2.0% of the sum insured per day. Or actual amount, whichever is less
3. Surgeon Anesthetist, medical practitioner, consultants specialist fees
4. Anesthesia, Blood oxygen, operation theater charges, surgical appliances, medicines and drugs, chemotherapy, radiotherapy, artificial limbs ….. and other medical expenses related to the treatment,
5. Pre hospitalization medical charges up to 30 days period immediately before the insured’s admission to the hospital for that illness or injury
6. Post hospitalization medical charges up to 30 days period immediately after the insured’s discharge from the hospital for that illness or injury

Note:

The amounts payable under 3 and 4 shall be at the rate applicable to the entitled room category. Incase insured opts for room wit higher rent than the entitled category as under 1, the charges applicable under 3 and 4 shall be limited to the charges applicable to entitled category.


The Complaint:

The above part claims nowhere that the amount, which will be reimbursed, will be according to some percentage between the entitlement and actual expenses made on room rent acquired by us. New India Assurance has misled me as nowhere the policy it is mentioned about the above and neither the agent who sold me this informed me of this complexity.

I was made to pay 60% of the bill of Rs 45615/- (excluding medicines expenses) for which I had to pay nothing.

I would like to take this up for serious action as many consumers like me may be duped into this with no clarity on what the policy offers to the insured. Ideally I should have been just paying the difference in the room rent plus the difference of charges for OT and visiting doctors as applicable to the room rented.
I have a mediclaim policy coverig period from 29.01.2009 to 28.01.2010 wherein I noticed that the Clause No.8.0 - Cumulative Bonus - was changed two years ago which states that "In case of a claim, the cumlative bonus earned shall be withdrawn on renewal of the policy". Does this mean that the cumulative bonus which I earned in respect of my past claim-free years of insurance, before the clause was changed, will also be withdrawn? For your information, I have earned Rs.135000/- as claim-free year bonus during the period fro 29/01/2005 to 28/01/2008, i.e. before the cumulative bonus clause was changed and earned Rs.15000/- during 29/01/2008 to 28/01/2009 after the clause was changed. Thereafter no bonus earned as it reached its limit of 50% of the sum insured. My question is:whether the company will take away all my bonus amount, including the bonus amount earned before the bonus clause was changed, if a claim is made? Request clarification.
sir
This P.Babu Rao & P.Veera Kasturi we have taken a medical policy collebration with corporationbank at Machilipatnam branch with A/c 0214/SB/01/019308. Actually for that purpose
we have open an account in corporation bank on 13/03/2009 but they did't take any mount for
medical insurance .After Five months again i contacted the branch on that time they debited
amount for medical insurance. This is before two monts back history after that one i did't get
any feedback like Medical Insurance Bond or Health Cards like. I am requesting you to inform
please what happend and when can i get the Health Cards or Medicial Insurance Bond.
Thankingyou
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I had a mediclaim from new india assurance from the tpa MD india, i took care of all the expenses and paid arround 99, 000 to the hospital, i got covered for Rs 92920. Even after submitting the documents, I was made to run arround and eventually the amount was give 4-5 months back, , , , dont know which mediclaim is best, , , ,
sir my famiy for mamber one deortter and one sun
I RANJIT SAR KAR ADDRESS- AJINKETARA CO HO SO LTD, FLAT 2.1 2ND FLOOR, C WING, VRINDAVAN COMPLEX, SUKHAPUR, NEW PANVEL RAIGAD- 410206, MEDICLAIM POLICE NO- 140802/34/09/11/00000729 DATED16/11/2009 PLACE PANVEL, SUM INSURED INR 700000/-, PREMIUM INR 8505/-
FOR YOUR INFORMATION I RECEIVED PREMIUM DOC. BUT TILL NOW I HAVE NOT REACEIVED ANY IDENTITI CARD, WHY[protected]?

3 MONTH ALREADY GONE WHY YOU NOT ISSUE IDENTITY CARD----?

EVERY THING IS CLEARED WHY SO LATE[protected]?

PLEASE FEED BACK ME AS SOON AS POSSIBLE.

MY MOBILE NO - [protected]

ADDRS. IS SAME ABOVE

THANKS

BEST REGARDS

RANJIT SAR KAR

NEW PANVEL
Same case has recently happened to me. My father was hospitalized last week here in Pune. I'd opted for cashless to avoid the admission time hassle. Total hospital bill came out to be 1, 20, 000 out of which only 45, 000 got approved after final bill (Initially TPA had approved Rs. 60, 000 but after final bill, this approval of 60, 000 was canceled) and I had to pay 75, 000 on my own.

My TPA, Mediassist has still not disclosed what all claims they have refused and for what reason. I MUST know this under the act of "Right To Information"

I am planning to claim this again through reimbursement. I would like to suggest all policy holders not to go for cashless if you can afford to pay initial charges as hospitals send huge amount of bill to TPA.

I also don't understand the reason behind different OT and other charges like Surgeon charges, Doctor's visit etc. for different room category. Patient from General ward/Semi-private and that from private/delus room both get operated in the same Operation Theater then why hospital charges more for the later category. I need some LOGICAL reason for this.

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