United India Insurance Ltd. — COMPLAINT AGAINST NO CLAIM(CLAIM NO.942120 )
I have a mediclaim policy o[censored]NITED INDIA INSURANCE LTD., the details of which
are as follows -
Policy Holder – Percy E Amalsadiwala
Patient’s Name - MEHRU PERCY AMALSADIWALA
EMSL ID - UI-GOLD[protected]
POLICY NO - 181302/48/09/97/00000262
SUM INSURED - RS.50,000/-
The patient was suffering from Fissures and Anal Spasm & was operated by Dr. Mukund Patel on 18-Nov-2009 & discharged on 19-Nov-2009.
The Doctor went out-of-station soon after few days of operation. On his return in-spite of being informed that the claim papers have to be submitted within 7 days of the patient being discharged, the Doctor denied to sign the claim papers & insisted that the same should be filed only after the completion of treatment. (We made him read condition 5.4 of the Policy that clearly states that the claim papers & all supporting documents should be filed within 7 days of the patient being discharged, but of no avail).
The Doctor signed the claim papers only on 04-Dec-2009 & gave us a certificate for the completion of treatment & we submitted the same on 07-Dec-2009 i.e. within 3 working days. Discharge card & all the invoices were given by the Doctor on 04-Dec-2009 only. Hence the claim was filed by us on 07-Dec-2009.
We got a Query Letter(attached herewith) dated -13-Jan-2010, from E-Meditek; asking us for the reason of late submission of file & in reply to which we gave them a letter on 03-Feb-10, explaining the above mentioned reason.(Attached herewith – Reply to Query Letter).
(Please note that the Query Letter didn’t reach our address & I collected the same from Mr.Vijay, E-Meditek-Surat on 27-Jan-10).
After few days of the submission of the reply to their Query Letter, Mr.Vijay verbally informed me that the claim has been rejected on the basis of late submission of file. I met Mr.Ashish, (Manager, E-Meditek, Surat) who told me to get a letter from the Doctor mentioning that it was his (Doctor’s) mistake & the same would not be repeated again but the Doctor denied to give the same & on the contrary challenged the rule(that the claim papers & all supporting documents should be filed within 7 days of the patient being discharged)itself. The Doctor maintained, “the Claim papers should be submitted only after the completion of treatment which have been done & hence my duty is fulfilled”. He advised us to challenge the insurance company in the consumer court.
Now in a rift between the Insurance Co. & the Doctor, it is finally the policy-holder who has to suffer. The Doctor & the TPA (E-Meditek) are unwilling to communicate directly with each other & on the contrary the Insurance Company has rejected our claim in-spite of being informed about the genuine reason for the late submission of file.
If the Doctor knowingly disregards & ignores the Insurance Company’s rule, is that the policy-holder’s fault?
Why doesn’t the Insurance Company directly communicate with the Doctor?
Due to the purposeful & sheer ignorance of the Insurance Company (& E-Meditek) and the unessential adamance of Doctor, the Policy-holder has to suffer(mentally as well as financially).
We were waiting for the “NO CLAIM LETTER” which we got only on 18-Mar-10(which is very blur & cannot be read easily), after around 1 month of being verbally informed that the claim has been rejected.
I request the concerned authority to interfere in this matter and help us get our well deserved claim. I also request you to take stringent actions against the Insurance Company & the TPA (E-MEDITEK) for unnecessarily rejecting the claim & harassing the Policy-holder.
Hope you understand the matter & act on it as soon as possible.
Thanks & Regards,
Mob – [protected]/[protected]
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