[Resolved]  Oriental Insurance Company — Wrong rejection of medical claim

Address:

Shimla, Himachal Pradesh

Medical Insurance Reimbursement Claim in r/o Claim no: 2188925 amounting to Rs. 1,22,334/- (against PNB Oriental Royal Insurance Policy No. 263100/48/2012/264 ; MA-ID[protected] in r/o Mr. Anil Kumar Sharma having Saving Account no. [protected] at PNB, Argyle House Branch, The Mall, Shimla - 171001

Mr. Anil Sharma, the claimant/insured had suffered Brain Stroke and immediately admitted at the Artemis Hospital, Gurgaon (Haryana) on 4.1.2012 from where he was discharged on 12.1.2012. TPA had denied cashless facility on the plea that the claimant was having history of Diabetes. When the treating doctor certified that the Brain Stroke was neither due to Diabetes nor he was being treated for Diabetes, TPA requested the claimant to submit claim papers only for reimbursement after discharge. When claim papers were submitted, TPA rejected the claim now on the plea that the claimant had a history of Hypertension which was wrong. The patient has never suffered from Hypertension till date and as such there was no question of such treatment. Despite the fact that the treating doctor repeatedly certified that the patient did not have any history of Hypertension and he was not suffering from Hypertension and an occasional BP reading of 150/80 mmHg during hospitalisation of a 67 yrs old patient does not make him a patient of hypertension and even in non hypertensive patient, blood pressure can rise after Brain Stroke, still the TPA rejected the claim. Detailed registered post representations with all related papers (61 in no.) had been submitted to the Oriental Insurance Co. on 30.4.2012 with two subsequent reminders to all concerned by emails including customer Service Deptt. but the claimed amount has not been reimbursed till date. Please intervene in the matter as the claimant (67 yrs) recovering from Brain Stroke is unfortunately under lot of mental stress due to callous attitude and injustice by the Insurance Co & TPA by wrongfully rejecting the claim without any logic, ryme & reason but by an imaginary & incorrect plea despite repeatedly certifying on the contrary by the treating doctor. Choosing the course of litigation in Consumer Court may not be medically advisable for a patient recovering from Acute Brain Stroke but in case the Insurance Co. is not considerate, there is no option but to seek remedy fighting for justice and in that case the Insurance Co. will be liable for all the consequences. An early action is requested in the interest of justice.

Thanks & Regards
Parveen Kohli (On behalf of Mr. Anil Sharma)
5187 Modern Complex, Manimajra, Chandigarh-160101
(M) [protected]