New India Assurance — illegal deduction from the medical insurance claim

Address: 380015

Sir / madam,

Vide email dated 26.08.2017, i have lodged a complaint, on behalf of my father, who was a policy holder of the new india assurance company limited being policy no.[protected] against illegal deduction carried out by your company from claim application to the tune of rs.51, 042/- being the admission / treatment charge of sterling hospital, ahmedabad. As stated in the earlier email dated 26.08.2017, out of a total claim amount of rs. 51, 042/-, your company has initially approved only rs. 22, 090/- by deducting an amount of rs. 28, 952/-.

Pursuant to the complaint lodged through the aforesaid email, a further amount of rs. 5, 450/- has been deposited electronically in my father's sbi account on 08.12.2017. However, till date, no intimation / communication has been received with respect to deposit of the said amount as well as the reasons behind the deduction of remaining amount from the total claim application of rs. 51, 042/-. The said act on part of your company is against clause 5 of annexure-i (Grievance redressal procedure) of insurance regulatory and development authority of india (Protection of policy holders interest) regulations, 2017 which specifically put a burden on the insurer to inform the complainant of the option to take up the matter before insurance ombudsman in case grievance is not resolved in favour of the policy holder or partially resolved in favour of the policy holder. Similarly, clause 33 (D) of insurance regulatory and development authority of india (Health insurance) regulations, 2016, specifically states that where a claim is denied or repudiated, the communication about the denial or the repudiation shall be made only by the insurer by specifically stating the reasons for the denial or repudiation. Even principle of natural justice requires that your company should inform the claimant in writing, specific reasons for denying or partially denying the claim of the policy holder which in the present case your company has not done. Thus, the act of your company is clearly a breach of principle of natural justice as well as notifications and regulations issued by irda to that effect, which are binding to your company.

Vide this email, your company is again asked to provide reasons in writing for denying the full claim of my father, failing which, as a legal heir of complainant late shri anilbhai v. Joshi, i would be constrained to take necessary legal action against your company at the cost and consequences of your company, which please note.

Regards,

Nirav a joshi,
Advocate,
Gujarat high court.
(Son and legal heir of late shri anilbhai v joshi, policy holder and complainant)