New India Assurance — rejection of claim

Address: The New India Assurance Co Ltd, B./201,Pinky Galaxy, Opp Big Bazar, Kapurbawdi Junction Majiwade, Thane (west) 400607., 400607

I subramani. K. Vishwanath one of the policy holder of your esteemed organization. My policy no.[protected]. My customer id is po07403916.

My policy is in force for the last 15 years. This is the first time i came lodging my claim.

Brief facts

Myself along with my spouse mrs padma subarmanian was admitted to sri sri college of ayurvedic science and research hospital, 21st km, kanakpur main road, udyapur post, bangalore 500 082 from 25.02.2019 to 05.03.2019 under the care of dr ganesh puttur under registration no. 185602 and 185606.

After the discharge from the hospital we lodged our claim with healthindia insurance tpa service pvt ltd, having their office at neelkanth corporate park, 4th floor, kirol road/village, vidyavihar society, vidyavihar west, mumbai 400 086.

The said policy was valid from 28.03.2018 to 27.03.2019. My claim was within the validity period.

On receipt of the claim, tpa allotted claim no. Hi-nia[protected] for myself, and hi-nia[protected] ext - (0) for my spouse mrs padma subrmanian.

The new india assurance co ltd, majiwade, thane (D. O.170100) vide their letter no. Up/health/2018-19/183 dated 04.04.2019 informed that “ as per new india mediclaim policy - claim 4.4.06-expenses arising out of or related to obesity are not payable (Clause highlighted and attached). Hence this claim is repudiated as no claim.”

The letter dated 04.04.2019 was received by me on 18.04.2019 through vichare courier service. Vide my email dated 25.04.2019 to the branch to inform us the reason for the delay and also informed that there was no attachment along with the said letter. What a casual approach you have still not responded to my said letter. Don’t you think it is deficiency of service?

Further, when the claim is not admissible as per the policy, you have to return the documents, which your great institution has not done that may be the practice of great institution like you. It is one way fooling the public.

As regards my claim, the tpa vide their letter dated 25.03.2019, followed by reminder dated 01.04.2019, 08.04.2019 and 15.04.2019 had called for the following documents for settlement of claim.

Required complete set of indoor care records with treatment chart.
Required all investigation reports supporting final diagnosis.

The matter was taken up with the said hospital through email. The hospital vide their email dated has informed as under that “as per our management policy, we are not allowed to give copy of any medical records (Ipd and opd) of patient admitted in our hospital. But viewing of the case sheet is permitted within the hospital premises itself in presence of hospital authority.” the same was forwarded to the tpa. However, tpa vide their letter dated 15.04.2019 informed that “due to non - receipt of below requirement which is mandatory, we are here by closing your claim.”

Query no query
1 required complete set of indoor case records with treatment chart
2 required all investigation reports supporting final diagnosis.

I understand, that sri sri ayurveda hospital is one of the member and having membership id 9328906 em. If the hospital is the member, then how can they deny to give copy of the documents, then on what credentials they became the members. It is not the duty of the member hospital to accept the terms and conditions of the insurance company and tpa. If the insurance company says that they will not part out with the copy of medical records then who is the sufferer it is the insured for no valid reason. He pays the steep premium these days you charge, the hospital gets the hospitalization bills and tpa is rewarded by the insurance company by giving huge commission for refusing the claim on flimsy grounds so that insurance company make huge profit.

I may not be the first patient to be admitted to the said hospital, there may other patients who might have got admitted and lodged their claims and how the same was passed it is a matter of question which tpa and insurance company has to answer. Possibly i have not greased the palms of the person handling my case in tpa.

I understand from some of my friends (Who are also your employee) who got admitted to the said hospital and they have got the reimbursements under said mediclaim policy. How did they get the reimbursement without documents is a matter of question even though he is a staff. I will see to it that this matter gets investigated from your vigilance cell.

I would like to share with you that your tpa has grievance portal, and i had lodged my grievance in their portal under ref no. 3898 till date i have got no response from them and it is still lying unattended. What a shame.

Lastly, i request you once again to direct the tpa to take up with the hospital directly or depute a person for copy of the documents as they are having branches all over india.