Dear Sir/Madam,
I am writing to formally register my strong objection and grievance regarding the manner in which the hospitalization claim of my father, Sh. A.P. Naithani, under Policy No. 215601/48/26/04032, has been handled by Oriental Insurance Company and its appointed TPA.
I had purchased and continuously renewed medical insurance for my father, a senior citizen, for approximately five years or more. During the renewal in February 2026, I opted to enhance the Sum Insured from ₹2 lakh to ₹4 lakh, in good faith and in accordance with the policy terms. The policy was duly renewed and the enhanced Sum Insured was accepted by the Company.
On 27th of August 2026, my father developed serious health complications. Considering his age and condition, we immediately took him to Amrita Hospital, Faridabad, where the initial investigations, including blood tests and ultrasound, were undertaken by us on an OPD basis. Based on the ultrasound findings, the treating doctors advised hospitalization for further investigation and treatment.
During hospitalization, a CT Scan was conducted, following which the doctors advised further investigations, including Endoscopy and FNAC. These investigations subsequently indicated a serious and newly diagnosed cancer-related condition. Since my father was primarily suffering from jaundice and was required to undergo further treatment, the doctors advised discharge with further treatment and investigations to be continued subsequently.
At the time of discharge, the hospital submitted the complete medical records, discharge summary, investigation reports and other relevant documents to the TPA/Oriental Insurance for processing of the cashless claim.
We were then made to wait for approximately four hours before receiving an authorization, which was substantially lower than the applicable Sum Insured of ₹4 lakh. I subsequently spoke with Mr. Rakesh Seth, Ex-General Manager, Oriental Insurance, who advised that the case would be resubmitted for review. However, we were later informed that the Company was considering the policy as having only ₹2 lakh coverage on the alleged ground that the Sum Insured had been intentionally increased from ₹2 lakh to ₹4 lakh during the February 2026 renewal and that the doctor had mentioned loss of appetite for approximately six months.
This reasoning is highly concerning and is not acceptable.
We immediately discussed this matter with the treating doctor, who subsequently provided a written clarification stating that “Sh. A.P. Naithani is a newly diagnosed patient of advanced carcinoma gall bladder, with a short history of constitutional symptoms for approximately two months, with new-onset jaundice and low-grade fever for the preceding 4–5 days. The carcinoma gall bladder is not a pre-existing disease and was newly diagnosed during the present episode”.
This clarification was also submitted by the TPA to Oriental Insurance for reconsideration. Despite this, we were again made to wait for several hours without receiving a satisfactory authorization, ultimately leaving us with no practical option but to pay more than ₹80, 000 plus from our own pocket, despite having a valid insurance policy with a Sum Insured of ₹4 lakh.
Our Formal Objection
The Company cannot, in our respectful submission, simply infer that enhancement of the Sum Insured during renewal was made with an intention to obtain an undue insurance benefit merely because a symptom was subsequently mentioned in the medical history.
A symptom or constitutional complaint cannot automatically be equated with a pre-existing disease, particularly when the treating specialist has expressly clarified in writing that the carcinoma gall bladder is newly diagnosed and not a pre-existing disease.
If the Company seeks to restrict the enhanced Sum Insured or invoke any exclusion, waiting period, pre-existing disease clause or other policy condition, we request that you provide the specific policy clause, underwriting basis, medical assessment and documentary justification relied upon for arriving at such a decision.
An insurance contract must be administered strictly in accordance with its terms and applicable regulatory principles. Any ambiguity or adverse interpretation should not be used mechanically to defeat a legitimate claim, particularly in a case involving a senior citizen suffering from a newly diagnosed life-threatening illness.
It is also extremely distressing that a senior citizen suffering from cancer, jaundice and significant discomfort was made to remain at the hospital for more than eight hours, largely awaiting clarity/authorization from the insurer/TPA. The delay caused considerable physical pain, mental trauma and distress to both my father and our family.
Our Demand
In view of the above, I hereby formally request Oriental Insurance Company to:
Immediately reconsider the claim in its entirety based on the complete medical records and the treating doctor's written clarification.
Honor the applicable ₹4 lakh Sum Insured, subject only to genuine and specifically applicable policy terms and exclusions.
Reimburse the amount that we were compelled to pay from our own resources due to the denial/restriction of the cashless authorization.
Provide a written explanation identifying the exact policy clause and medical/underwriting basis under which the enhanced Sum Insured has been restricted to ₹2 lakh.
Provide the complete claim assessment/rejection or authorization rationale, including the TPA's assessment and the Company's final decision.
I am giving the Company seven (7) days from receipt of this email to review the matter and provide a satisfactory written resolution.
Please treat this communication as a formal grievance and notice for resolution.
Should the matter remain unresolved within the above period, I will be constrained to pursue the remedies available to me under the applicable insurance and consumer-protection framework, including escalation through the Company's grievance mechanism, the Insurance Ombudsman, the appropriate Consumer Commission, and any other regulatory or legal forum having jurisdiction.
I will also seek appropriate relief for the financial loss suffered by us, along with compensation, costs and other reliefs permissible in law arising from the manner in which this claim has been handled and the avoidable hardship caused to a senior citizen during a serious medical emergency.
I sincerely hope that Oriental Insurance will review this matter objectively and resolve it at the appropriate level without compelling us to initiate formal proceedings.
This is not merely a question of ₹80, 000 or the difference in the authorization amount. It concerns the fair and ethical treatment of a senior citizen and the legitimate expectation that a medical insurance policy, duly purchased and renewed, will provide meaningful assistance when the insured actually needs it.
Praveen Naithani
[protected]
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