Hi,
My father, a senior citizen, In July 2022 underwent Cataract Surgery & submitted my claim(Claim No:[protected] for Rs 55, 816/-(including pre-post hospitalization charges)
we are a Cigna TTK customer from the year 2019 onwards and renewed our health insurance policy diligently each year. also, we don't have a single claim in these 3 years except this one.
I submitted all the docs prior to hospitalization and the cashless claim was approved for 38000/- and the hospital (L.V.Prasad Eye Institute, Madhapur) proceeded with the operation which cost 54, 000, and the hospital applied for a final settlement for 54, 000. However, the TPA denied the cashless claim from the hospital. I had to pay the amount from my pocket even though I hold an insurance policy with clean previous record history.
Then I had to apply for reimbursement. Then again, the TPA came in and denied the claim saying two points:
We have received claim documents for, claimant Mr. Rama Rao admitted at L V Prasad Eye Institute - Hyderabad hospital from 15 Jul 2022 to 15 Jul 2022 with the complaints of RT Eye cataract Claimant is covered under ManipalCigna Health Insurance Prohealth Group insurance Union Bank customers - Floater policy since 11 Jun 2019As per the available documents patient had K/c/o Pelvic girdle pain 4 yrs which is material to policy decision and was not disclosed in proposal form at the time of policy inception. Had these conditions been disclosed in the proposal form which forms the basis of the policy contract, we would not have issued the policy to this member at all. Claim stands denied under policy condition VI.1 duty of disclosure. We regret our inability to admit this liability under the present policy conditions. We also reserve the right to repudiate the claim under any other ground/s available to us subsequently.
The points to be noted are,
"how come My father has Pelvic girdle pain ??" as far as I know this pain will be a post symptom for pregnant women! and they denied telling the same reason!
and PGP refers to Previous glasses prescription.
This is so disappointing that none of the call center guys have any clue on what needs to be done because of the inactions of the backend team. They kept promising that it would be reimbursed & a complaint was also raised against it. at last, the claim is denied (CashLess and Reimbursement as well)
This is really pissing us off. We carry the health insurance policy to cover all our health needs in spite of the problems being pre-existing or post-discovered diseases after policy inception. This is like threatening the customers and disrespecting us after we diligently renew and pay for the policy.
I doubt the senior management is aware of these issues because, the overall SoPs seem to be substandard & at this technology era, we are forced to call the call center multiple times with no proper update/progress...it's literally going into a black hole...they kept on asking us same questions again & again & again.
and would circulate and escalate calls among many divisions !!!
It's so surprising how management was able to tolerate such inefficiencies for such a prolonged period of time.
This is such a foolish mistake of one of the people (s) from Medi Assist who set the wrong information which led to my claim denial and policy termination.
I doubt the sincerity of both the Insurance Company & TPA in settling this claim, hence we are forced to be harsh and look for resolutions.
FYI:
Ticket nums: [protected], [protected]
Claim No: 29268767
Policy No:[protected]/03/00
Regards,
Abhilash,
S/O Ramarao
Medi Assist India customer support has been notified about the posted complaint.
