New India Assurance — Unwarranted deduction of claim -out of mediclaim settlement

Date: 9th MARCH, 2021
From : Narendra Damani
Dharma Nagar, 247, Linking Road,
Borivali west, Greater Mumbai
Maharashtra- 400 091

Dear Sir/Madam
Claim No.: Against New India –[protected] settled by Raksha HI TPA Pvt. Ltd.
Insurance Company Claim no.- TP[protected]
Policy No.[protected]- valid upto 16/3/2021 in the name of Mr Narendra Damani.
Patient name /DOA- Mrs. Rachana N. Damani/4th October to 10th October, 2020 at United Multi Speciality Hospital- Borivali West, Mumbai
Diagnosis- Covid-19 +
Dear Sir
PFB my written complaint lodged with Insurance company New India, on January 7, 2021 for unwarranted deduction of my claim amount from my Mediclaim policy, but there was no reply from Insurance Company at all. therefore after completion of 30 days, I again lodged my complaint on February 6, 2021 thru IRDA complaint portal vide token no.[protected] and entity reference number NIA00041678 and waited for 15 days, but there was no reply neither from New India nor from IRDA officials. Therefore after completion of 15 days, as per the process displayed at IRDA complaint site, I escalated the complaint matter on February 23, 2021. However to my surprise, when I checked today the status of my complaint on IRDA site, the IRDA portal mentions that New India communicated to me on February 26th, 2021 itself stating no change in their stand, and accordingly the IRDA Complaint portal officials have closed internally my complaint, without asking the complainant whether he has received the reply from New India and whether am I satisfied or not? Further on calling today at their customer care number- We were told that new India has communicated to us, but inspite of telling them, that we have not received any reply from New India on our claim as claimed by New India to IRDA, IRDA official is not ready to listen and asked us to approach Bima Lokpal directly, as they cannot do anything further, and even they cannot forward us the reply received by them from New India on our complaint. This is very strange. The process needs to be transparent and accountability needs to be fixed, as customer has no clue what is going on and even IRDA who is the highest authority is not able to help the common man even when he files the written complaint.
Therefore I am approaching your goodselves with hope to help us to review our claim complaint and arrange to award the unwarranted amount deducted by New India while settling my Mediclaim bill w.r.t. Covid-19 treatment of my spouse.
Hope this complaint will receive the priority and hearing will be done asap to settle the matter.
Narendra Damani
Date: 7th January, 2021
From : Narendra Damani
Dharma Nagar, 247, Linking Road,
Borivali west, Gretaer Mumbai
Maharashtra- 400 091

To, New India Assurance Co. Ltd.

Dear Sir/Madam
Claim No.: New India –[protected] settled by Raksha HI TPA Pvt. Ltd.
Insurance Company Claim no.- TP[protected]
Policy No.[protected]- valid upto 16/3/2021 in the name of Mr Narendra Damani.
Patient name /DOA- Mrs. Rachana N. Damani/4th October to 10th October at United Multi Speciality Hospital- Borivali West, Mumbai
Diagnosis- Covid-19 +

Dear Sir/madam
Sub; Unlawful/Unwarranted illegal deduction from my Covid-19 treatment claim
Submission – Thru E-Mail
This is to inform you that I have taken above mentioned policy which was renewed well before Covid-19 lockdown in India. I have been associated with new India for many years.
My spouse Mrs. Rachana Damani was admitted for covid-19 treatment between 4th October to 10th October at United multispeciality Hospital, Borivali west, Mumbai hospital and her total hospital bill was Rs.1, 80, 105/- for which all the documents and bills incl. reports were provided to Raksha TPA for settlement
However Raksha TPA after review, assessed and settled the claim only for Rs. Rs.131, 632 /- instead of total bill of Rs 180, 105 .( i.e Deduction of Rs.48, 473.i.e. 27% deduction out of the total medical bill) on the pretext of internal capping/ not admissible/ beyond per day limits/ consumables ( incl Mask/Sanitiser, etc. which was provided by the Hospital as part of Covid-19 treatment) and some amount deducted towards Ayurvedic treatment/bio waste, etc.
As you all know. Covid-19 being new type of Global pandemic disease, the patient once admitted in the Hospital for treatment of Covid-19 is fully dependent on the Hospital Doctors for the treatment of this new type of disease and has no say at all in such new type of treatment being given to him/her as the patient, by the Hospital Doctors, as Doctors try their best to save the patient by all type of allopathy/ayurvedic/non medical items/recently known successful remedies (incl. PPE Corona Kit) as newly introduced defenses available in the public domain thru reliable medical sources as simultaneous treatments and available and known measures in such global pandemic situation across the country.
Further the bio waste of such disease/treatment also needs to be specially disposed off, so that such contagious disease should not spread. This all involves cost and being passed on by the Hospital on the patient and patient expects in such stressed circumstances to be borne by the Insurance Company under Mediclaim policy as special disease treatment charges and not as routine treatment charges and should not be put under lens for scrutiny of such each charges which are newly introduced.
However If Insurance Company feels that any specific Hospital is charging more than prescribed/ normal charges, they should put into public notice about such hospital name and warn the public that due to unnecessary levying high charges, such hospital treatment will not be considered at all for Mediclaim settlement or their will be major deduction in submitted bills.
It is really very sad to know that the deduction has been made out of my mediclaim bill for Rs. 48, 473/ - on the following grounds which is unwarranted:
1- Rs.4900/- Assistant Doctor charges
2- Rs.7000- Non medical items
3- Rs.2100/ - Bio Medical waste
4- Rs.5250 – Supplement charges
5- Rs..500/- admission fee
6- Rs.3500/- Mask
7- Rs. 13300/- towards PPE kit charges ( payable Rs.600 per kit per day only)
8- Rs.1423/- N95 Mask, Gloves, sanitizers, etc. And
9- Rs.10, 500/- - Ayurvedic integrated treatment charges
I would like to strongly emphasise that the treatment of Covid-19 patient has been very critical and all Hospital Doctors incl. staff put their best to save the patient from this new pandemic disease at any cost even by giving all types of new treatments( even if it is not allopathic or non customary treatment) as even the global doctors are still in learning mode at present.
However when patient recovered after treatment, the treatment used by them while treating such patient in stressed situation, which is acceptable to the patient is questioned by the Insurance Companies as excess or not allowed/permissible like grounds. I would like to advocate that there should not be any capping or ad hoc deduction under the name of Ayurvedic/Consumable or Capping by any Insurance Companies especially for Covid-19 Patient treatment bills under any circumstances considering the global pandemic treatment being experimented all over the world.
I further state that myself as an individual, has no say or bargaining power in front of the hospital and had to pay whatever amount was charged to me. Therefore I sincerely request that I should not be penalised and the full hospital bill claim amount should be paid to me, as billed by the hospital.
The ombudsman ( Shri Milind Kharat) vide his award order no. IO/Mum/A/HI/[protected] dated 24th November, 2020 ( vide complaint Ref no.MUM-H[protected] in the matter of Mr. Abhay Chhapia and Bajaj Allianz GIC may be noted in such matters, where he ordered to pay the patient majority of the deductions made in the mediclaim.
I strongly protest the unwarranted deductions from my Medical Hospital bill made by the TPA on behalf of Insurance Company and legally demand the above said deducted amount as eligible under mediclaim from the Insurance Company.
If such deductions are allowed, it will put undue hardship on the policyholders and the patient, and I request that such practice of any random deductions out of Covid-19 patients bill, should not be allowed to be implemented in this pandemic times. I would further like to state that people take Mediclaim policies for such uncertainties only and hence should be considered with open mind and not as routine matter.
I am enclosing herewith, the claim settlement advice / voucher showing settled/deductions ( hospital bill being large file- not attached-but certainly available with Raksha TPA) received by me for the review and ratification by ordering immediate settling of the deducted amount by TPA of the Insurance Company, considering the ongoing global pandemic situations and its treatments in the hospitals, where patient has no say but to receive the treatment as being given to him/her in good faith to come out of this dreaded disease/situation.
Pl. note that if I do not hear within 15 days from the date of this letter, from your office, I will proceed to file my claim with the Ombudsman .
Thanking you
Narendra Damani
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Mar 09, 2021

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