| Address: 143001 |
| Website: nationalinsuranceindia.nic.co.in |
Sir,
It is humbly submitted as under:-
1. that i man mohan jerath, resident of 129, puda colony, green avenue, amritsar, panjab, is an old policy holder of national insurance company ltd. bo 4, mall road, amritsar (branch code 401208) and for the last several years, purchasing mediclaim policies from them. similarly, i purchased cashless mediclaim policy no.401208/48/13/[protected] from them, on 11.8.2013 for
Rs. 1, 00, 000/-, towards general medical and rs. 200, 000/- towards critical illness under varishtha medi claim policy. which was valid for the period till 10.8.2014.
2. that during the validity of the policy, ito get admitted in fortis escorts hospital, amritsar, for a day and claimed rs. 12, 482/- leaving behind insured amount of rs., 87, 518/- towards general medical and rs.200, 000/- towards critical illness.
3. that i again suffered from heart problem and was to be admitted in fortis escorts hospital, amritsar on 15.10.13 for my heart bypass surgery. after the surgery, i was discharged from hospital on 23.10.13. the hospital raised an inpatient bill for rs. 2, 01, 200/- dated 23.10.2013 ’ and claimed the amount directly from park mediclaim tpa (admn.), new delhi, but they sanctioned only rs. 87, 518/- and disallowed rs. 113682/-.
4. further on the date of discharge i. e 23.10.2013 and again on 2.11.2013, i purchased certain follow up medicines for total amount of
Rs. 2650/-. immediately after discharge from fortis escorts hospital, i on 19.11.2013 filed a claim with your bo 4, mall road, amritsar, enclosing therewith all the documents as listed therein, which includes:-
A. claim form
B. original park mediclaim card no. 91310715
C. inpatient bill for rs. 201200/- issued by fortis escorts hospital
D. grant letter dated 23/10/13 for rs. 87518/- from tpa, new delhi..
E. receipt dated 28/10/13 for rs. 113682/- issued by fortis escorts hospital, of their having received the balance payable amount from me.
F. three medicines bills for rs. 2650/-.
5. that at the time of issuing the said policy, i was told that the policy will cover rs. 1, 00, 000/- against all kinds of mediclaim and
Rs. 2, 00, 000/- against all kinds of critical illness. despite repeated reminders for the terms and conditions of the policy in detail, your bo no.4 mall road, amritsar failed to supply any terms or conditions except whatever was mentioned in the insurance policy, supplied to me.
6. that in the mail sent by tpa, new delhi to fortis escorts hospital (escorts heart and super speciality institute ltd., amritsar), it is clearly mentioned by tpa that only rs. 87518/- has been granted and hospital must collect the excess amount over and above the authorisation amount from the concerned member prior to discharge from the hospital as per rules and regulations of the hospital and advised the hospital to arrange further authorization for the balance amount from me, for which the i was forced to make the payment directly to the hospital vide my cheque no. 008049 dated 28.10.13 for rs. 1, 13, 682/- of bank of india, mall road branch, amritsar, duly acknowledged by fortis escorts hospital, vide their receipt no. ipd 89644 dated 15.10.2013.
7. that when the matter was taken up by me, with your afore mentioned branch and tpa the tpa informed vide their communication no. nicchi/18465 dated 19.3.14 that further amount of rs. 9724/- has been sanctioned by them against the balance claim amount of rs. 116332/-and they disallowed rs. 106608/-. i again took up the matter with your amritsar branch no.4 and tpa, requesting them to make the balance payment of rs. 106608/- also and vide my mail dated 28.3.14, requested tpa to send the break up of amount allowed and disallowed.
8. that tpa vide their mail dated 8.4.14 intimated me that claim has been approved for rs. 40, 000/- and reason for heavy deductions of rs. 76332/- is the compensation for cabg will be limited to 20% of s. i of critical illness under section-ii.
9. that i again took up the matter, with your branch no.4 and tpa to make the balance payment to me as their disallowing of
Rs. 76332/- is highly unjustified and unwarranted. your branch no.4 vide their mail dated 24.5.14 ‘ requested tpa to clarify, under which section of the policy 20% (critical illness) amount approved, so that they can satisfy the insured, regarding the claim otherwise please send break up to insured directly.
10. that the tpa vide their letter dated 5.8.14 intimated me that they have closed the claim file.
11. that the tpa also vide their mail dated 18.6.15 and dated 19.6.15 intimated me that my request is being forwarded to the concerned department for processing. they also mentioned that in case the complainant is not satisfied with their settlement, he may take up the matter with the policy issuing office, as the complete claim file has been sent to them on 12.6.15 for their final decision.
12. that i further vide my regd. letter dated 22.8.15 again requested your bo no.4, under intimation to tpa, to make the full payment of rs. 116332/-, failing he shall be compelled to file a complaint with the district consumer dispute redressal forum.
13. that tpa vide their mail dated 12.3.15 again intimated me of their having sanctioned rs. 40000/- against pending claim of
Rs. 116332/-. the tpa have been asking me to send them receipt for full and final settlement of the amount to enable them to send payment of
Rs. 40000/- and further threatening to close the file, in case i do not send them my approval for the same.
14. that since then i have been following up the matter with your bo no.4, but with no result. your bo no.4 has been playing, delaying tactics with one or the other excuse and are unnecessarily delaying to make the genuine payment of pending claim.
15. that the refusal to admit my genuine claim by your bo no4 and tpa is most unjustified, unwarranted and unfair and has caused harassment and mental agony to me your bo no.4 and tpa are not only deficient in service, but has also played unfair trade practice with me.
18. that from the perusal of all the facts stated here before, your goodself will come to the conclusion that the action taken by your bo no.4 and tpa in not admitting my genuine claim is highly unwarranted, illegal and highly unjustified and against the principles of law and natural justice.
It is therefore, prayed that my grievances kindly be examined on merits and your bo no.4 and tpa please be directed to make payment of my very genuine claim..
Sep 12, 2016
Complaint marked as Resolved
National Insurance Company customer support has been notified about the posted complaint.
Verified Support
Aug 09, 2016
National Insurance Company Customer Care's response Dear Sir,
We thankfully acknowledge your grievance.
Due to technical complicacy of grievance redressal, it is very difficult for us to redress grievance in this forum.
You are requested to write your grievance at customer.[protected]@nic.co.in
You can also directly lodge grievance at nationalinsuranceindia.nic.co.in or igms.irda.gov.in
Inconvenience caused is deeply regretted.
Renew Policy Details:
Customer ID: [protected] Customer Name: TAPAS NARAYAN CHAUDHURY.
Product Code: MC Product Name: National Mediclaim Policy
Policy Effective Date: 09/08/2016 Policy Expiry Date: 08/08/2017
Your Quote Number is : R[protected]
Your Premium Payable is: null
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