The New India Assurance : Mediclaim — Not settlement of mediclaim : wrong imposing of Exclusion Clause.

 
6 Reviews
 MRS. SMITA CHANDRATRE
From : Mrs. Smita S Chandratre,
5, Gajra Park – I,
Opp, Gajanan Mandir,
Indira Nagar, Nasik – 422009


Date : 18.05.2009

To,

Resp. Ombudsman,
{For New India Assurance Co.}
Mumbai.

Respected Sir,

Re : Notice against Wrong Consideration of Exclusion Clause [4.3] imposed under Mediclaim Policy …

Ref : Policy No. 150800/34/08/11/00000562
CCN : MDI 0283557/ ID NO. MD15-004107370
Mr. Sudhakar Janardan Shukla by
The New India Assurance Co. {TPA : MD India Pvt. Ltd.}


This refers my application dated 08.04.2009 regarding reconsideration of the above mentioned mediclaim. I am thankful to you that you have taken follow up of the same, and I was called by The New India Assurance Co., Nasik Division, for discussion in this case.

Accordingly, I met Divisional Manager, The New India Assurance Ltd., Satpur, Nasik Division on 15.05.2009. Surprisingly, he behaved with me in such a way that he was unaware about this claim or he don't wish to entertain me. I spared my valuable time to meet him only because of request from New India Assurance Ltd. authorities; however, his response was very cool which make me nervous.

Despite of this, I put the facts of the above claim in front of Divisional Manager, already mentioned in my letter dated 08.04.2009. Apart from this, he focused again and again upon the same point,

“ SUM ASSURED ENHANCED BY RS. 50000/- IN CURRENT YEAR.
EXCLUSIONS FOR TWO YEAR [4.3] APPLICABLE FOR PRESENT ILLNESS
HENCE THE CLAIM IS RESTRICTED FOR PREVIOUS YEAR SI+CB I.E. RS. 57500/- ”

I, again strongly object for the reason as above conveyed by him. I would like to let you know that, while issuing the policy, the above EXCLUSIONS FOR TWO YEAR [4.3] CLAUSE or any policy schedule, or, terms and conditions, was/were not conveyed to me, nor it is provided after the policy issued till this date. Moreover, on current year renewal, while increase in S.A. on Insurer's part, this is not conveyed/ provided to me which please note.

As a consumer, please let me know under the Right To Information whether I have, right to get the terms and conditions of my contract or not ? and if yes, then whey the said Insurer failed to provide me the same ?

It is a matter of fun that when I asked about this to the New India Assurance Co. Officials, Nasik Division, they told me that, this is not a duty of Insurer to provide the schedule while giving the policy, and the policyholder should come and collect the same from Company, if he want. You may check the facts in this argument/reply, from Mr. Balasaheb Thorat, my Agent, who is witness of this episode. This proves the lacuna, irresponsible sense in Insurer's system.

Moreover, please note again that this is not a fresh Policy contract with the Insurer but, in continuation of the previous contract only.

While considering increase in S.A. on Insurer’s part, there is no Medical Exam. called for. This means that Insurer is satisfied upon the Physical Condition of the Assured as he has already examined him while issuing a fresh policy. Facts of the Claim are not varying due to increase of the S.A. on Insurer's part. I have already mentioned rest of my points in my letter dated 08.04.2009, which may please be referred again.

In view of the above, I once again state that this is a wrong consideration of EXCLUSION CLAUSE by the New India Assurance Co. Ltd. As
1. I have not been provided any policy schedule or exclusion clause.
2. This is not a fresh policy, but just a renewal of contract, health conditions remains as if at the time of taking the policy.

You are, requested to advice the New India Assurance Company not to impose this Exclusion Clause in this case and reconsider the Claim in full. If I do not get response from your end within 15 days, the way is open to me to fight against this injustice before a court of law.

Thanking you,
Yours faithfully,
sd/-
Mrs. Smita S Chandratre.

Through Email ...
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The New India Assurance Co. Mediclaim .... — : Notice against Wrong Consideration of Exclusion Clause [4.3] imposed under Mediclaim Policy …

From : Mrs. Smita S Chandratre,
5, Gajra Park – I,
Opp, Gajanan Mandir,
Indira Nagar, Nasik – 422009


Date : 18.05.2009

To,

Resp. Ombudsman,
{For New India Assurance Co.}
Mumbai.

Respected Sir,

Re : Notice against Wrong Consideration of Exclusion Clause [4.3] imposed under Mediclaim Policy …

Ref : Policy No. 150800/34/08/11/00000562
CCN : MDI 0283557/ ID NO. MD[protected]
Mr. Sudhakar Janardan Shukla by
The New India Assurance Co. {TPA : MD India Pvt. Ltd.}


This refers my application dated 08.04.2009 regarding reconsideration of the above mentioned mediclaim. I am thankful to you that you have taken follow up of the same, and I was called by The New India Assurance Co., Nasik Division, for discussion in this case.

Accordingly, I met Divisional Manager, The New India Assurance Ltd., Satpur, Nasik Division on 15.05.2009. Surprisingly, he behaved with me in such a way that he was unaware about this claim or he don't wish to entertain me. I spared my valuable time to meet him only because of request from New India Assurance Ltd. authorities; however, his response was very cool which make me nervous.

Despite of this, I put the facts of the above claim in front of Divisional Manager, already mentioned in my letter dated 08.04.2009. Apart from this, he focused again and again upon the same point,

“ SUM ASSURED ENHANCED BY RS. 50000/- IN CURRENT YEAR.
EXCLUSIONS FOR TWO YEAR [4.3] APPLICABLE FOR PRESENT ILLNESS
HENCE THE CLAIM IS RESTRICTED FOR PREVIOUS YEAR SI+CB I.E. RS. 57500/- ”

I, again strongly object for the reason as above conveyed by him. I would like to let you know that, while issuing the policy, the above EXCLUSIONS FOR TWO YEAR [4.3] CLAUSE or any policy schedule, or, terms and conditions, was/were not conveyed to me, nor it is provided after the policy issued till this date. Moreover, on current year renewal, while increase in S.A. on Insurer's part, this is not conveyed/ provided to me which please note.

As a consumer, please let me know under the Right To Information whether I have, right to get the terms and conditions of my contract or not ? and if yes, then whey the said Insurer failed to provide me the same ?

It is a matter of fun that when I asked about this to the New India Assurance Co. Officials, Nasik Division, they told me that, this is not a duty of Insurer to provide the schedule while giving the policy, and the policyholder should come and collect the same from Company, if he want. You may check the facts in this argument/reply, from Mr. Balasaheb Thorat, my Agent, who is witness of this episode. This proves the lacuna, irresponsible sense in Insurer's system.

Moreover, please note again that this is not a fresh Policy contract with the Insurer but, in continuation of the previous contract only.

While considering increase in S.A. on Insurer’s part, there is no Medical Exam. called for. This means that Insurer is satisfied upon the Physical Condition of the Assured as he has already examined him while issuing a fresh policy. Facts of the Claim are not varying due to increase of the S.A. on Insurer's part. I have already mentioned rest of my points in my letter dated 08.04.2009, which may please be referred again.

In view of the above, I once again state that this is a wrong consideration of EXCLUSION CLAUSE by the New India Assurance Co. Ltd. As
1. I have not been provided any policy schedule or exclusion clause.
2. This is not a fresh policy, but just a renewal of contract, health conditions remains as if at the time of taking the policy.

You are, requested to advice the New India Assurance Company not to impose this Exclusion Clause in this case and reconsider the Claim in full. If I do not get response from your end within 15 days, the way is open to me to fight against this injustice before a court of law.

Thanking you,
Yours faithfully,
sd/-
Mrs. Smita S Chandratre.

Through Email ...
RAM SWAROOP SHARMA Date:[protected]

24B, NIMTOLLA GHAT STREET,

KOLKATA – 700 006, ( WEST BENGAL ).



To

THE NEW INDIA ASSURANCE COMPANY LTD.

Divisional Office : 712500,

II Floor, Mount Casa Blance Building,

(Old No.701-702), 260 Anna Salai,

Near Anand Theatre,

CHENNAI – 600 006.





SUB : CANCELLED UNWANTED INSURANCE POLICY FROM YOUR SIDE.



REF. : 1) GOOD HEALTH POLICY CERTIFICATE NO.GH SEP 08 14117

2) PERIOD OF INSURANCE : 01/09/08 TO 31/08/09



Sir,



I have received your letter with the above policies which I never purchased/ applied but it is utmost surprise that you had issued that insurance policy. You have received the policy money from my CITI BANK CARD NO.[protected], How you collected money from my card without my consent.



Please take immediate stapes about the matter as early as possible.



I am requesting you that please cancel the unwanted policy and refund the premium and service tax amounts.



You are requested to settle the matter itself with the CITI BANK & otherwise I have no option to take matter with the legal court.



Thanking you.



Yours truly,









( Ram Swaroop Sharma )



CC to 1) CITI BANK, Cardmember Services, PO Box No. 4830, Anna Road Post Office, Chennai- 600002.



2) CITI BANK, Cardmember Services, Kolkata.



3) Reserve Bank Of India, NS. Road. Kolkata – 700 001.



4) The New India Assurance Company Ltd.



N.S. : All the concerns are requested to do the need full to protect the loss I have to bear.





--- On Tue, 10/2/09, nia25 <nia25@vsnl.com> wrote:



From: nia25 <nia25@vsnl.com>
Subject: Re: Wrongly Issued A Good Health Policy Caertificate No.GH SEP 08 14117
To: "HEMANT BAGLA" <elcon_investment777@yahoo.co.in>
Cc:
Date: Tuesday, 10 February, 2009, 3:45 PM



To CITIBANK

Please refer certificate no.712500/14117/GH SEP08. Card member disputes the coverage for insured person Ms.Tinki Joshi claimed that he does not know that person and requested for cancellation.

Please probe into this matter and kindly arrange to cancel the same as requested by the card member.

Regards,

CUSTOMER CARE
NIA DO712500


----- Original Message -----
From: HEMANT BAGLA
To: nia25@vsnl.com
Sent: Tuesday, February 10, 2009 11:33 AM
Subject: Fw: Wrongly Issued A Good Health Policy Caertificate No.GH SEP 08 14117






----- Forwarded Message ----
From: HEMANT BAGLA <elcon_investment777@yahoo.co.in>
To:
Sent: Friday, 6 February, 2009 12:47:08 PM
Subject: Wrongly Issued A Good Health Policy Caertificate No.GH SEP 08 14117


From

RAM SWAROOP SHARMA

24B, Nimtala Ghat Street,

Nr SBI

Kolkata-700 006.

Phone :[protected], [protected]



Date:[protected]



To

The New India Assurance Company Ltd.

260, Anna Salai,

Chennai-600 006.







Ref : Customer I.D.-[protected]



Sub : Wrongly Issued A Good Health Policy Caertificate No.GH SEP 08 14117



Dear Sir,



We receive a Good Health Policy Certificate from your side, which is wrongly issued by you. The name of insured person is TINKI JOSHI, DOB[protected], but I do not understand who is TINKI JOSHI. There is no TINKI JOSHI in my family. So please cheque the matter as early as possible & cancelled the above policy.



Thanking you



Yours truly,



Ram Swaroop Sharma
I was applied for NIACL.I know i have exame on october 25th 2009.But i didn't got hall_ticket.i don't procedure also please send hall_ticket to my mail.
By
Bharathi D%Maldakal
My mediclaim policy number 130600/34/09/66/00005708 i have submit my mediclaim file before 70 days but i have not received claim amount
To
07.09.2012
M/s. Medicare TPA Services(I)Pvt. Ltd.,
6, Bishop Lefroy Road,
Kolkata-700 020 Kind attn. Dr.
Tapas Kumar Chaudhuri

Dear sir, Complaint against your
forceful clause of 4.3 which are
not related with
submitted documents under policy No.

511604/34/11/01/00001378 and claim no. 0112362.

After a prolonged period I received your reply about the status
and before received your letter the Insurance company The New India
Assurance Co. Ltd., Ultadanga Branch under branch code 511604 they
have replied to me on behalf of you as on my query relating to above
claim.

As on your imposed clause and repudiation of the said claim I
strongly oppose and give you an advice please study and vouch my
documents which are not related with your imposed clause and you
should study the clause of 4.3 because you are a doctor and medical
adviser of the TPA.

It is very strange that after reply to email you are as the TPA
not to response on my raised question and always trying to ignore me
about the claim matter and since my lodge of claim your status
forwarded by the insurance company and you were silent.

Henceforth, I once again request you to vouch the submitted
documents and withdraw your imposed clause of 4.3 and try to send my
claim value. For your knowledge and reassess the pending matter I am
sending the clause clarification of 4.3 as stated below please study
it.

4.1 During the first year of operation of the insurance cover,
expenses on treatment of diseases such as cataract, benign prostatic
hypertrophy, hysterectomy or menorrhagia or fibromyoma, hernia,
hydrocele, congenital internal diseases, fistula in anus, piles,
sinusitis and related disorders are not payable. If these diseases are
pre-existing at the time of proposal, they will not be covered even
during period of subsequent renewals.

Kindly acknowledge it and try to arrange my pending claim value
as on my submitted documents.

Thanking you,

Yours faithfully,


Sujit Pramanik

69/33/A, Ukilabad Road, PO: Berhampore,

Gorabazar, West Bengal-742101

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    The New India Assurance : Mediclaim - Not settlement of mediclaim : wrong imposing of Exclusion Clause.