The New India Assurance Co Ltd — Non reimbursement of medical insurance

Pragnesh Shah
Attachments
6:17 PM (22 minutes ago)
to customercare.ho, dr.snehal.barot, crcmbaroda, jh.pandya, complaints

Dear Sir /Madam

With reference to above subject Query raised by Company of Diagnosis HYPERHOMOCYSTEINEMIA

For Genetic or normal We have enclosed documents as per list mentioned below.

1. Reply letter raised by SVP

2. Revised Medical Certificate – Dated 15/01/2022

3. Request letter dated 11 th Jan 2021

4. Medical Certificate dated 16th Nov 2021

5. Discharge Summry dated 28/10/2021

6. Summry of expenses after Discharge of Rs. 1.725/- bills already submitted

7. Summry of expenses from 26/10/2021 to 27/10/2021

8 . Letter to Raksha TPA

9. Letter to New India Assurance –Branch office

Recommendation for Repudiation for claim No. TP[protected] Ref No. [protected] dated 4/12/2021

Prposer’Name

Pragnesh Ajitbhai Shah

Policy Number

[protected]

Patient Name

Sejal Pragnesh Shah

Hospital Name

Diagnosis/Name

Policy Period

Age

Dev Office/Agent Code

Insurer

Claim Ref Number

Date of Admission

Sum Assured /Buffer

Claim

Gender

Relation with Insured

Corporate Name

Member ID Number

Date of Discharge

Claim Amt

Sardar Vallabhbhai Patel Institute

Hyperhomocysteinemia +Newly Detected Autoimmune Hasmimoto Thyroiditis

12- March – 2021 to 11-March-2022

44

D1210209

The New India Assurance Co. Ltd.

[protected]

26-Oct-2021

800000

Reimbursement

F

Wife

Individual

N[protected]

28-Oct-2021

Rs. 12, 747/-

Observations and Opinion (As per Submitted Documents)

Receipt of Claim Documents as per available details the patient was treated for HYPERHOMOCYSTEINEMIA and as per medical certificate patient was newly detected autoimmune hashimotothyroiditis with vit B12 deficiency from 26/10/2021 to 28/10/2021. As per diagnosis has a waiting period of 48 months which shall be applicable afresh. As per New India Floter Mediclaim Policy Clause No 3.14 g Genetic Diseases or disorders with a sub limit of 25 % of Sum Insured per policy period of 48 Months waiting periods.

Note : For the Voverages defined in 3.14 waiting periods, if any shall be applicable afresh i.e. for both New and Existing Policy Holders w.e.f. 1st October 2020 . Coverage for such illness or procedures shall only be availbale after completion of the said waiting periods.

Hence claim stand non payable. Hence Claim is recommended for reudiation and file for required action.

Opinion

As per opinion from side I am eligible for reimbursement of against my mediclaim policy and against this decease.

As per your opinion this claim will be reimbursment after completion of 48 months w.e.f. 1st Oct 2020 but there is no knowledge given neighther insurance company nor insurance agent /TPA

I was admitted in Hospital dated 26/10/2021 and Discharge dated 28/10/2021 and at that time I already inform Development officer Mr.D.M.Shah Agency Code – 210209. I paid Mediclaim policy from year 2002 to 2022 and I have Mediclaim Policy documents from year[protected] to[protected] so I am eligible for reimbursement of my Mediclaim. I already all supporting origional Documents to Insurance Company/TPA

Meaning of Mediclaim is reimbursment of medical treatment taken by patient. I have age of 44 and I have no pre decese and I never taken medicine against this decease . I was Discharge 28th Oc 2021 and till dated I have not receive my claim amt. Today in this critical situation if insurance company /TPA not paid then as patient /Relative face mentally depression and face financial problem. Client has taken mediclaime policy for financial support igiven by Insurance Company /TPTA against medical treatment taken from Hospital. Patient / Relatives never knowledge of medical /Doctor Language of decease. Hospital /Doctors /Laboratories taken primary treatment and then after different kinds of medical reports and charge huge amt to patient. When patient was admitted at that time mentally situation of patient and Relative was very bad.

There was no knowledge given of Rules and Regulations by Insurance Agent / Insurance Company/TPT/Hospital to Patient and this reason patient /Relative was suffer financial problem.

Insurance agent resposibility to help to client for remibursement of claim. There is very long procedure for reimbursement of mediclaim. I Request kindly reimburment of claim within 1 week from submission of documents to company so patient /relative not face financial problems

I have receive only mediclaim polices every year and no other docuemnts of TPA/ Deceases list from Insurance Company / Agent.

I have mentioned detail below of Family Floter mediclaim policies with name of Pragnesh Ajitbhai Shah / Sejal Pragnesh Shah /Jainam Pragnesh Shah from[protected] to[protected].

__________________________________________________________________________

Period Policy Number Premium Amt. Policy Amt.

[protected] [protected] [protected]

[protected] [protected] [protected]

[protected] [protected] [protected]

[protected] [protected] [protected]

[protected] [protected] [protected]

[protected] [protected] [protected]

[protected] [protected] [protected]

[protected] [protected] [protected]

[protected] [protected] [protected]

[protected] [protected] [protected]

__________________________________________________________________________

I humble request kindly reimburment my claim as early as possible.

Thanking You

--
PRAGNESH SHAH
A-9 NEW RAMJI PARK CO-OP HSC LTD
B/H : MANGLYA TOWER
BHATTA, PALDI, AHMEDABAD-380007
M - [protected]
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New India Assurance customer support has been notified about the posted complaint.
Feb 18, 2022
Updated by pragnesh999
NON REIMBURSEMENT OF CLAIM
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