[Resolved]  United India Insurance Co Ltd — CLARIFICATION AS TO AMOUNT DEDUCTED ON REASONABILITY CLAUSE

Address:

Mumbai Suburban, Maharashtra

From:
SANJAY RAJDHARI SINGH
201 SPRING LEAF “5-C”
LOKHANDWALA TOWN SHIP
AAKURLI ROAD
KANDIVALI-EAST
MUMBAI – 400101

TO,
MS MINA PATEL
UNITED INDIA INSURANCE CO LTD
DIVISIONAL OFFICE
BORIVALI (WEST)
MUMBAI

DATE: 19 – 08 – 2011

FINAL REMINDER

Respected Sir / Madam,

Ref.: INDIVIDUAL HEALTH INSURANCE POLICY NO.120900/48/10/97/00008396
CLAIM NO.MUM-0311-CL-0000987

Reg.: CLARIFICATION AS TO AMOUNT DEDUCTED ON REASONABILITY CLAUSE
PLEASE REPLY TO MY LETTER.

Why am I asking to REPLY FOR MY LETTER as when I approached the UNITED INDIA INSURANCE COMPANY LTD REGIONAL OFFICE, MS ADIGHA (CLAIMS MANAGER) told me that the same will be replied by the DIVISIONAL MANAGER MS MINA PATEL (DIVISIONAL MANAGER) But, unfortunately MS MINA PATEL directed the matter to MS SHILPA (TTK REPRESENTATIVE) and MS SHILA assured to give reply in WRITING.

MEANWHILE OUR REPRESENTATIVE AMET MS.SUDHA KULKARNI (BRANCH MANAGER TTK) AND DISCUSSED THE MATTER. SHE ALSO NOTED DOWN ALL THE THINGS AND ASSURED TO GET BACK TO ME BY EVENING YESTERDAY[protected] BUT THERE WAS NO REPLY FROM HER TOO.

HENCE today i.e. 19-AUG-2011 when we followed up the matter with TTK their representative MR MITESH / RITESH (TTK REPRESENTATIVE) tried to justify the same ORALLY and just told that we are not able to give you anything in writing, what ever we had given CALCULATION SHEET is the final and also told me to take YOU TAKE WHAT EVER ACTION YOU WANT TO TAKE… Is this a way to talk to POLICY HOLDRS / REPRESENTATIVE?

PLEASE JUSTIFY and REPLY.

SANJAY RAJDHARI SINGH

NOTE: HAVE CURTSY OF COMMUNICATION SYSTEM TO REPLY TO ONE’S LETTER

LAST FAX DETAILS …

1. LETTER DATED[protected]
2. REMINDER-I DATED[protected]
3. REMINDER-II DATED[protected]

With reference to the above, I would like to inform your good selves that the amount deducted on the grounds of REASONABILITY CLAUSE is not JUSTIFIABLE to me hence needs to inform you the following

1. The REASONABILITY CLAUSE means What?

a. I had made certain Enquiries at different Hospitals in Suburban areas like MALAD, BORIVALI and so and upon such an enquiry I came to know that the surgery of APPENDIATIS is being charged at the rate of 50,000/- to 60,000/-

b. But I preferred DHIRRAL HOSPITAL which is ECONOMICAL for me as well as for the company to settle the claim.

PLEASE JUSTIFY!!!


2. How the TPA can put all the charges to REASONABILITY CLAUSE such as …

a. STAY CHARGES for 10 days which according to the Treating doctor’s decision & requirement of the ailment and for which the doctor had already given clarification to that effect.

b. Where as the SURGERY CHARGES are Rs.4,000/- which is quiet NOMINAL and REASONABLE now on this too the TPA had put CUT to all the charges charged by the HOSPITAL

PLEASE JUSTIFY!!!



CLAIM LODGED: 15 – 03 – 2011

For your reference I am sending herewith the SHORT FALL REQUIREMENTS raised by the TPA …

(1) SHORT FALL No. : MUM – 0311 – CL – 0000987 – S01 Dated: 16/03/2011

GREAT the SHORTFALL was raised just one day after the CLAIM LODGED but sorry to inform that the same was not received till 28 – 03 – 2011 by me but up on follow up I had been informed on phone that there are some SHORT FALL REQUIREMENTS. And the same were taken prints at my agents office.(copy attached)

I replied the same SHORTFALL immediately on same day 28 – 03 – 2011 (Copy attached) as to

(a) TREATING DOCTORS CARTIFICATE & DATE OF SURGERY
(b) USG REPORTS

From 28 – 03 – 2011 till 06 – 06 – 2011 (69DAYS) there were NO RESPONSE from the TPA

PLEASE JUSTIFY!!!

(2) SHORT FALL No. : MUM – 0311 – CL – 0000987 – S02 Dated: 06/06/2011

Again requirement as to A/S/F – REQUIRED HISTOPATH REPORT …

I mentioned in the reply of SHORT FALL No. : MUM – 0311 – CL – 0000987 – S02 Dated: 06/06/2011 that the FINAL DECISION is of the treating doctor and according to the treating doctors Advise & Guidance, the HISTOPATH REPORT were not done (Copy of treating doctors certificate attached herewith)

PLEASE JUSTIFY!!!

AND NOW THE TPA HAD SETTLED THE CMAIL ON 01 – 07 – 2011 BUT THE CLAIM CHQ RECEIVED ON 05 – 07 – 2011. WHERE IN WHICH THE REASONABILITY CLAUSE IS APPLIED BY TPA.

PLEASE JUSTIFY!!!

PLEASE CONSIDER MY PLEA TO REIMBURSE THE WRONG DEDUCTION ON REASONABILITY CLAUSE AS EARLY AS POSSIBEL AS TO GAIN FAITH AND TRUST BOF YOUR POLICY HOLDERS AS TO INSURANCE & MEANING OF INSURANCE.

Thanking you

SNAJYKUMAR R SINGH

ENCL AS ABOVE

(a) SHORT FALL No. : MUM – 0311 – CL – 0000987 – S01 Dated: 16/03/2011 & REPLY THEREOF
(b) SHORT FALL No. : MUM – 0311 – CL – 0000987 – S02 Dated: 16/03/2011 & REPLY THEREOF
(c) CUSTOMER SATISFACTION FEED BACK FORM