Universal Sompo — Mediclaim under iob healthcare plus policy
Sub:complaint against universal sompo general insurance co. Ltd
Ref: medi claim under iob health care plus policy: 2817/52877690/03/000, policy coverage: upto rs.2 lakhs, insured name: subrata mondal, patient name: subrata mondal,. Treatment period: nov 10, 2016 to nov 14, 2016, tpa: e-meditek, tpa id no: [protected]a, tpa claim no:[protected], irda reference no:[protected]. Empaneled hospital name: narayana hospital, andul road, howrah (Near shalimer rail station
With reference to the above admission, hospital final bill was: rs.49533.00
Tpa approval against the claim was: rs.37210.00, thus the deduction was: rs.12323.00
I approached both tpa & insurance company for its clarification but they didn’t bother to reply to my repeated mails. Then i reported the matter to irda. When irda initiated the issue, they clarified the reasons for deductions by a letter but it didn't satisfy me. Then i requested irda to escalate the issue for further scrutiny but they didn’t move it further to resolve. Therefore, i request you to take up the matter with the tpa & as well as with the company. I am ready to cater you every needed support as advised by you. Following few points are my main agenda.
It is their empaneled hospital and should operate within the protocol of the policy of the firm.
The tpa had deducted the hospital claim amount on each and every expense category and the major head are investigation-rs7630/-, consultant charges-1450/-, room rent-1200/-, admin charge-1100/-, oxymeter charge-500/- etc.
Universal sompo, in thier letter to me, had admitted that their tpa had deducted rs.1600/- erroneously and they are ready to pay me the amount if claimed. If i wouldn't take up the matter then this faulty deduction would had gone un-noticed. So this seems to be case of forgery. The insurance company deducted one amount saying that the investigation is not related to the main ailment. Now my point is, if it is so then they should have taken up the matter with the hospital. Why the patient should suffer for the wrongdoings of the hospital?
Once my expenditure was well within the limit of my coverage & in their empaneled hospital, they should have approved the whole amount without any deduction. I request you to take appropriate action against them for the harassment and ill-legitimacy and refund me the amount rs.12323/- which i paid to the hospital with suitable compensation. Please kindly do the needful at the earliest. Feel free to contact me in case you need any information / clarification.
[Apr 05, 2017] Universal Sompo customer support has been notified about the posted complaint.
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