The Oriental Insurance Company Limited — Repudiation of legitimate mediclaim

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380001

Policy No: 141200/48/2015/20968 EMSLA TPA Claim Number:[protected] R.L. Number EMSLT.P.A/REJ/98072 Reference: EMSLTPA_19_10_2015_ E_ 24112015. IM_2778_ 2859 dated 27 November, 2015 Name of the Patient: Dhwani ( Daughter) Acknowledgement of Claim dated 03/07/2015.. Page No.1 Please find attached herewith Complaint against The Oriental Insurance Company limited for repudiating my legitimate claim giving reason that C3R is not proven treatment so claim is repudiated as per policy clause 4.13. which is totally baseless and as per latest correspondence as per policy Clause No: 2, 3 which is totally baseless. Recently The New India Assurance Company limited given authorization letter to Vasan Eye Care hospital For Rs.25800/- for C3R ( Treatment of Keratoconus ) (refer page No.2 ) The treatment is same and hospital is also same only Insurance Company is different. We request you to look in to the matter and give direction to insurance company to pay my legitimate claim. E-Mediteck has while rejecting Cashless informed that first you recover from the patient and submit the claim papers. (Refer Page 3). LEGAL STATUS: Judgment of THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT MANGALORE. COMPLAINT No: 82/2009 (Admitted on 16.04.2009) Sri.K.Parameshwara Bhat V/s . 1.Branch Manager, LIC of India, Mangalore 2.The New India Assurance Company Limited Divisional Office, 2nd Floor, Sri Ram Arcade, Opp: Head Post Office, Udupi – 576 101. The above said Aravind K underwent Keratoconus surgical procedure and got operated both the eyes at Nethra Dhama Hospital Bangalore on 30.7.2008 as well as on 31.7.2008 and incurred expenditure of Rs.40, 654-94. Judgement: That the eye surgery keratotomy underwent by Aravind K. is not excluded under the policy. However, the Complainant produced medical bills worth Rs.40, 404.94 as per Ex C2 which contains 4 medical bills. Therefore, we hold that the Opposite Party No.2 i.e., New India Assurance Company represented by its Divisional Manager is hereby directed to pay Rs.40, 404.94 being the medical reimbursement to the Complainant. And further we direct the Opposite Party No.2 to pay Rs.5, 000/- as compensation for the harassment and inconvenience. And Rs.1, 000/- awarded as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order. Your immediate action in the matter is requested. Thanking You. Nitin S.Shah Policy Holder