National Insurance Company — non-payment/rejection of mediclaim for grounds not mentioned in policy

Address:743123

1. My mother-in-law, suffered itbvro (Internal branch retinal vein occlusion) in 2017 during the 1st year of health insurance policy (Sr. Citizen's policy with national insurance corpn).
2. She was treated at disha eye hospitals, twice on 3/4/17 & 6/5/17. But nic rejected the mediclaims saying it is not payable as one of the medicines (Accentrix injection) used in treatment is not payable.
3. When contacted, the nic barrackpore office and medsave (The tpa) told me that accentrix injection is also used in cataract surgery and cataract surgery is not payable (As per clause 4.3 of the policy) in 1st year of policy.
4. They asked for the clarification of the doctor at disha hospitals, who (The surgeon at disha) certified on 20/12/17, that this disease (Itbvro) is not related to cataract.
5. Still nic rejected the claim on 4/5/18.
6. When contacted again, medsave, the tpa, asked me to submit a certification from the doctor at disha that the treatment was not just for administering accentrix injection, which the doctor certified in september 2018 and the claim file was again sent from nic to medsave.
7. Now medsave/nic is rejecting the claim saying itbvro is not covered under 1st policy year.
8. But as per the policy prospectus except cataract surgery, all other eye surgeries are payable.
So please look into the matter and the harassment by the nic/medsave.
9. Patient : anjali som
Id: p[protected]
Policy no. : 154501/48/16/[protected].
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