[Resolved]  New India Assurance Mediclaim Policy — Misinformation and non payment of claim

My sister Ms Priya Taneja has a cashless medical policy from New India Assurance Company Ltd (policy number 310600/34/09/11/[protected],

Recently my sister was admitted to Artemis Hospital Gurgaon for treatment
She was admitted to the hospital on 11th June 2009 for treatment. The procedure was a surgery in OT and post drainage of wound.

The sum assured on the policy in Rs 100000/- and it is cashless in nature.

According to the policy my sister was entitled for a room not exceeding 1% of the sum assured which was Rs 1000. We upgraded the economy room from 4 in a room to twin sharing which was being charged at Rs 2450/- per day with a promise to the hospital to pay the remaining amount.

The hospital staff at this point informed me that the charges for doctor visit and others will also change according to room type, which I agreed upon and I will have to pay just the difference in the amount of charges entitled and actual charges being made.

At the time of discharge on 14th June 2009 the hospital informed me that according to the policy I will have to pay 60% of the outstanding amount. After two hours of arguments and discussions with the TPA department Raksha I had to pay 60% of the bill payable even though my policy is complete cashless and the bill was only for Rs 45615/- while sum assured stands at Rs 100000/-.

When spoken to the TPA people they gave me some calculation and did not share with me a figure which will be given to the hospital. They asked me to read the regulations of the policy.

Henceforth the policy document only reads as follows:

Following reasonable, customary and necessary expenses are reimbursable under the policy:
1. Room boarding and nursing expenses as provided by the hospital/nursing home not exceeding 1.0% of the sum insured (excluding cumulative bonus) per day or actual amount, whichever is less
2. ICU.ICCU expenses not exceeding 2.0% of the sum insured per day. Or actual amount, whichever is less
3. Surgeon Anesthetist, medical practitioner, consultants specialist fees
4. Anesthesia, Blood oxygen, operation theater charges, surgical appliances, medicines and drugs, chemotherapy, radiotherapy, artificial limbs ….. and other medical expenses related to the treatment,
5. Pre hospitalization medical charges up to 30 days period immediately before the insured’s admission to the hospital for that illness or injury
6. Post hospitalization medical charges up to 30 days period immediately after the insured’s discharge from the hospital for that illness or injury

Note:

The amounts payable under 3 and 4 shall be at the rate applicable to the entitled room category. Incase insured opts for room wit higher rent than the entitled category as under 1, the charges applicable under 3 and 4 shall be limited to the charges applicable to entitled category.



The Complaint:

The above part claims nowhere that the amount, which will be reimbursed, will be according to some percentage between the entitlement and actual expenses made on room rent acquired by us. New India Assurance has misled me as nowhere the policy it is mentioned about the above and neither the agent who sold me this informed me of this complexity.

I was made to pay 60% of the bill of Rs 45615/- (excluding medicines expenses) for which I had to pay nothing.

I would like to take this up for serious action as many consumers like me may be duped into this with no clarity on what the policy offers to the insured. Ideally I should have been just paying the difference in the room rent plus the difference of charges for OT and visiting doctors as applicable to the room rented.

A copy of the above complaint has been submitted to the Grievance Cell of New India Assurance