Oriental Insurance Company — repudiation of claims on flimsy reasons no logic behind the same and repeated

Address:

Mumbai City, Maharashtra, 400078

My wife was hospitalised with jupiter hospital twice on april 20th 2017 to april 25th 2017 and 25th june 2017 to 30th june 2017. Following is the detail of our complaint letters to health tpa and oriental insurance for your refrence.
From:
Nita pankaj panchal/pankaj babulal panchal
C-1404, mahavir universe maven chs ltd,
Off l. B. S marg, next to kukreja complex,
Bhandup west,
Mumbai – 400078.

Dear sir/madam,

Subject: complaint against repudiation for 2 separate claims for reimbursement.

I the undersigned pankaj babulal panchal holder of the happy family floater policy of your company initiated on 07th july 2014 policy nos. As follow:
1. 131100/48/2015/5626 issue office name : mcdo20
2. 131100/48/2016/4420 issue office name : mcdo20
3. 131100/48/2017/3204 issue office name : mcdo20
4. 131100/48/2018/3331 issue office name : mcdo20

Claim no 1. April 2017.

My wife ms. Nita pankaj panchal who is the insured person in these policies was first admitted to dhanwantary hospital and intensive cardiac care unit (Mulund west) on the morning of 20th april 2017 at around 5:30am with complain of chest pain, nausea and vomiting where she suffered cardiac arrest and was given cpr and transferred to jupiter hospital (Thane west) at 8:05am to ccu 3 (Emergency assessment form attached). She was discharged on the 25th april 2017. Subsequently the claim was submitted claim no. 131100/48/2018/000608 with claim amount irs. 4, 13, 780.00.

We have received a pre repudiation letter stating reason:

Nita p. Panchal has submitted claim for acute anterior wall mi with vf with lvf in jupiter netralay. On scrutiny it was found that the ailment in this case has four years waiting period as patient is having past history of htn since 2000 as per doctor’s consultation note and the ailment is hence pre - existing. Insured has submitted policy copies from 14-17 as per clause 4.1 of new updated policy terms and conditions this claim stands repudiated.

To which we now submit the letter dated 10th may 2017 from the admitting doctor dr. Navin r. Davda which clearly states no past history of ihd and a subsequent letter dated 4th august 2017 which substantiate the claim of no past history of ihd and that the same has happened during her admission on 20th april 2017. (Both letter copies attached).

The above explanation is very clear and your reason of preexisting ailment is not valid hence we request your authority to look into the matter and reconsider our claim.

Attached documents at the time of lodging the claim no.1 at your andheri office and health tpa:

1. Copy of repudiation letter dated 2nd august 2017.
2. Letter from dr. Navin davda dated 10th may 2017.
3. Letter from dr. Navin davda dated 4th august 2017.
4. Admission history from jupiter hospital dated 20th april 2017.
5. Emergency assessment form from jupiter hospital dated 20th april 2017.
6. Jupiter hospital discharge letter dated 25th april 2017.
7. Claim form duly filled dated 27th apr.2017.

Claim no 2. June 2017.

My wife ms. Nita pankaj panchal who is the insured person in these policies was first complaining o[censored]rine infection on 23rd june at dr. Mahajan urology clinic at ghatkopar east and was prescribed medicines by dr. Ramesh mahajan for 5days and the next appointment was on 28th june 2017 (Letter attached).in the morning of 25th june on seeing no improvement and the situation getting serious she was admitted to dhanwantary hospital and intensive cardiac care unit (Mulund west) on the morning of 25th june 2017 at around 9:00am with complain of fever and chills, nausea and vomiting, abdominal pain, loss of appetite, loose motion etc. (Discharge card/doctor davda’s discharge letter attached) after initial medical treatment she was transferred to jupiter hospital (Thane west) at 19:27pm to ccu 2 (Discharge summary attached). She was discharged on the 30th june 2017. Subsequently the claim was submitted claim no. 131100/48/2018/002469 with claim amount irs. 1, 39, 651.00.

We have received a denial letter stating reason:

Hi-oic[protected] of nita p. Panchal
We have received the request for cashless hospitalization vide fax dated 06/27/2017. We have verified the coverage terms and conditions as per insurance plan.
On primary scrutiny of your request, we regret to inform you that we are unable to sanction cashless benefit.
Policy is in 3rd year, present hospitalization seems related to h/ohtn dm, hence cashless denied under clause 4.1 (Preexisting diseases).

To which we now submit the letter dated 8th august 2017 from the admitting doctor dr. Navin r. Davda which clearly states that it’s for the first time she has suffered from this ailment on 25th june 2017 (Letter copy attached).

The above explanation is very clear and your reason of preexisting ailment is not valid hence we request your authority to look into the matter and reconsider our claim.

Awaiting your early reply in this matter.

Thanking you,

Pankaj babulal panchal