Oriental Insurance Company — gross injustice & abnormal delay in settlement of medi-claim no [protected] in the name of mrs. anita jain under policy no 233902/48/2018/5050

vinod kumar jain

from Basi, Punjab

Address:

DURGAPURI HAIBOWAL, Ludhiana, Punjab, 141001

It is deeply disturbing that despite having submitted the truthful submission vide our letter dated 13th march, 2019 and through numerous verbal communications thereafter in clarification of query in response to your letter dated 04.03.2019, still, there does not seem an end to rigmaroles.
Your perfidious approach is writ-large when you conveniently denied of having received our above-referred letter dated 13th march, 2019, though received by you under recorded delivery, but preferred to close the claim file as no-claim. All these unfair acts and conduct is not only akin to rubbing salt on wounds of the sufferer but is a clear breach of trust violating the policy-holder’s interests regulations, 2017, especially against the provisions of regulation 27 of irdai (Health insurance) regulations, 2016.
My honest submission in my above-referred letter was/is sufficient to consider sympathetically, inter-alia, to reimburse the genuine expenses incurred on the treatment on my wife, which by all norms was instantaneous and sudden and myself as an insured or the insured person was never ever aware of nor ever felt any such complexity of pains etc.in the past or prior to policy nor ever diagnosed remotely rather my wife was quite hale and hearty as fit as fiddle. My wife had no signs or symptoms of such ailment prior to policy or even before hospitalization on 30.07.2018. Even, two ecg on record, prior to intervention, go to establish that there was no indication of any heart ailment.
There is no reason to assume it as pre-existing disease by any flight of imagination, especially, in view of the categorical opinion of the renowned cardiac surgeon dr. Sarju rahlan of prestegious dayanand medical college & hospital, ludhiana confirming vide its certificate dated 10.08.2018 that she had no previous history of any kind of treatment of hospitalization regarding coronary artery disease. The same is attached as ready reference. For the sake of brevity, my letter dated 13.03.2019 may also be read together here and reconsidered for the sake of justice. Any unpredictable or unknown ailment may take place with the human body which even the premier medical institute of the region could not diagnose at the very prima-facie by having undergone diagnostic procedures or through conservative observation by the attendant team of doctors.
So, it is absolutely wrong to presume it as pre-existing ailment by any stretch of imagination. It does not stand to any logical reason either under the protection of policyholders' interest regulations as envisaged by irda or in the ambit of insurance policy to capriciously apply that tool of settlement which preferably suits to your ends to squeeze an innocent customer monetarily & mentally by putting the insured on a disadvantageous pedestal by wrongly & illegally propounding as pre-existing ailment. Such an unfair term is void ab-initio. Rather, a misadventure is being made to decide the fate with pre-conceived mind and fallacy. I vociferously lodge my protest against this unfair act & conduct. Yours plea in the matter, without any trace of animosity, is ex-facie frivolous, malicious & misconceived intended to cause irretrievable loss to an innocent insured and thus, deserves to be deprecated in the given situation.
It seems that the envisaged concept of an insurer has been thrown out of the window by illegally denying the cashless facility. Thus, you even preferred to maintain a deafening silence and failed to settle & pay the rightful claim within 30 days on receipt of documents as per regulation 9 (5) irdai. The violation thereof is also punishable u/s 102 (B) of the insurance act, 1938.
Sir, your unlawful principle of coercion would not apply here in my case by taking a false shelter of an irrelevant plea distantly not related to the present claim. Instead, upright claim of a consumer should have been decided cordially while demonstrating coherence, cogency & candor. Such irrational tool of nitpicking, after any genuine claim, ought to have been avoided and rather, the contractual, statutory and regulatory obligation under the policy should be performed with professional diligence.
So, “healthy conflict resolution process” religiously demands that my claim be reimbursed in a quick-fix manner without any further delay in the fairness & fitness of things. I hope your good self shall not compel me to move on to any other path of conflict for rightful resolution. Humility and honesty come to a decision expediently.
Looking forward to having your prompt & positive response

Yours humbly,
(Vinod kumar jain)
B-34, 4641, street no.12, durga puri,
Haibowal kalan, ludhiana
Cell no. [protected]

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Oriental Insurance Company customer support has been notified about the posted complaint.

May 26, 2019

Updated by vinod kumar jain It is deeply disturbing that despite having submitted the truthful submission vide our letter dated 13th March, 2019 and through numerous verbal communications thereafter in clarification of query in response to your letter dated 04.03.2019, still, there does not seem an end to rigmaroles.
Your perfidious approach is writ-large when you conveniently denied of having received our above-referred letter dated 13th March, 2019, though received by you under recorded delivery, but preferred to close the claim file as No-Claim. All these unfair acts and conduct is not only akin to rubbing salt on wounds of the sufferer but is a clear breach of trust violating the Policy-Holder’s Interests Regulations, 2017, especially against the provisions of Regulation 27 of IRDAI (Health Insurance) Regulations, 2016.
My honest submission in my above-referred letter was/is sufficient to consider sympathetically, inter-alia, to reimburse the genuine expenses incurred on the treatment on my wife, which by all norms was instantaneous and sudden and myself as an insured or the insured person was never ever aware of nor ever felt any such complexity of pains etc. in the past or prior to policy nor ever diagnosed remotely rather my wife was quite hale and hearty as fit as fiddle. My wife had no signs or symptoms of such ailment prior to policy or even before hospitalization on 30.07.2018. Even, two ECG on record, prior to intervention, go to establish that there was no indication of any heart ailment.
There is no reason to assume it as pre-existing disease by any flight of imagination, especially, in view of the categorical opinion of the renowned Cardiac Surgeon Dr. Sarju Rahlan of Prestegious Dayanand Medical College & Hospital, Ludhiana confirming vide its certificate dated 10.08.2018 that she had no previous history of any kind of treatment of hospitalization regarding Coronary Artery Disease. The same is attached as ready reference. For the sake of brevity, my letter dated 13.03.2019 may also be read together here and reconsidered for the sake of justice. Any unpredictable or unknown ailment may take place with the human body which even the Premier Medical Institute of the Region could not diagnose at the very prima-facie by having undergone diagnostic procedures or through conservative observation by the attendant team of doctors.
So, it is absolutely wrong to presume it as pre-existing ailment by any stretch of imagination. It does not stand to any logical reason either under the Protection of Policyholders' Interest Regulations as envisaged by IRDA or in the ambit of Insurance Policy to capriciously apply that tool of settlement which preferably suits to your ends to squeeze an innocent customer monetarily & mentally by putting the insured on a disadvantageous pedestal by wrongly & illegally propounding as pre-existing ailment. Such an unfair term is void ab-initio. Rather, a misadventure is being made to decide the fate with pre-conceived mind and fallacy. I vociferously lodge my protest against this unfair act & conduct. Yours plea in the matter, without any trace of animosity, is ex-facie frivolous, malicious & misconceived intended to cause irretrievable loss to an innocent insured and thus, deserves to be deprecated in the given situation.
It seems that the envisaged concept of an INSURER has been thrown out of the window by illegally denying the cashless facility. Thus, you even preferred to maintain a deafening silence and failed to settle & pay the rightful claim within 30 days on receipt of documents as per Regulation 9(5) IRDAI. The violation thereof is also punishable U/S 102(B) of the Insurance Act, 1938.
Sir, your unlawful principle of coercion would not apply here in my case by taking a false shelter of an irrelevant plea distantly not related to the present claim. Instead, upright claim of a consumer should have been decided cordially while demonstrating coherence, cogency & candor. Such irrational tool of nitpicking, after any genuine claim, ought to have been avoided and rather, the contractual, statutory and regulatory obligation under the policy should be performed with professional diligence.
So, “Healthy Conflict Resolution Process” religiously demands that my claim be reimbursed in a quick-fix manner without any further delay in the fairness & fitness of things. I hope your good self shall not compel me to move on to any other path of conflict for rightful resolution. Humility and honesty come to a decision expediently.
Looking forward to having your prompt & positive response

Yours Humbly,
(Vinod Kumar Jain)
B-34, 4641, Street No.12, Durga Puri,
Haibowal Kalan, LUDHIANA
Cell No. [protected]