| Address: Thane, Maharashtra, 401105 |
With reference to above mentioned policy, I would like to inform you that we do not had any per-existing disease at the inception of the policy on 20/10/2015 and almost one year has been passed since opting the policy. Now My wife Nishita Vyas got severe pain in her stomach on 9th Oct, 2016 late night after which we had rushed to Dr Madhavi Goel (Padmavati Maternity, Bhayander East, Thane) where she had given injection for pain relief and informed us go for the medical reports next day, Now after going through the medical reports my wife diagnosed with a Cyst in her left Ovary and Doctor suggested to go for immediate surgery or else there was a risk of Cyst torsion and it may threat to her life so we have decided to go for the Laparoscopy surgery as suggested by the doctor.
However I admitted my wife on Wednesday i.e. 12th Oct, 2016 to the above mentioned hospital as the Surgery was been scheduled on Thursday i.e.13th Oct, 2016 morning at 10 am and since the said hospital is tied up with your insurance company we had given all the policy documents for the approval of Cash Less Treatment. Now after admission in the late afternoon I received a call from your executive that we have rejected your approval for the claim on the basis that the said Complication is excluded and will be covered after two years from the inception of the policy and the same has been mentioned in the Terms and Conditions of the Policy documents.
Facts of the Case
At the time of selling the above mentioned policy Companies executive had only informed me the two things as follows,
1) Policy will come in force after completion of one month except Accident.
2) Pre-existing disease will be covered after two years.
Now on the basis of above mentioned conditions one month has already been passed since the inception of the policy and neither my wife was suffering from any pre-existing disease, Also none of company's executives had disclosed any information and facts regarding the Exclusions at the time of inception of the policy nor I had received any document specifying the Terms and Conditions i.e. their so called “Exclusions” along with the original Policy Documents and the soft copy of terms and policy mailed is not to be considered as a valid document since it was not digitally signed so they do not have any right to reject my claim unless they had sent me a hard copy of Terms and Policy list duly signed with original policy documents, also my policy is already in force.
Conclusion:
The above scenario clearly shows the company's intention to defraud the customers by selling the policy by giving fake & incomplete information which is not only against the business ethics but against the interest of the General Public as per the constitution, Also I got the information from google that many fraud cases has been registered against the said company in relation to Cheating and Defraud the Customers which proves the company's intention.
However the said matter was been taken up with their grievance redressal cell and subsequently to Insurance Ombudsman vide Complaint no INS/OMB//PUN-G[protected] where all the required documents was duly submitted and hearing was been held by the Insurance Ombudsman on 16/01/2017 in which i would like to inform you that the Respected Ombudsman had only favored the Insurance company where all the misconduct of the said insurance company such as incomplete communication, irresponsible behavior and inappropriate business ethics has been ignored and only mistakes of the innocent customer like me has been focused that why i had not asked for the original Terms & Condition documents when i received the policy and given the judgement in the company's favor dismissing the claim.
Sir I would like to convey that this is not a defeat of a common men but it is a defeat of our country's system where this type of fraudulent companies survives on the hard earned money of a common men.
Prayer :
Hope for your intervention in the above matter and direct the company to grant me a reimbursement of the medical expenses incurred amounting to Rs 76, 070/- along with an appropriate compensation for unnecessary harassment, details of communication with the ombudsman along with a copy of bills is enclosed herewith for your ready reference.
Particulars Amount
Medical Reports (MRI, Citi Scan, Sonography) 13, 500/-
Medical Reports (Blood Test and Cyst Test) 4, 070/-
Medicines as mentioned by Doctor along with dressing charges 1, 000/-
Hospital Expenditure (Including Surgery and whole Treatment) 57, 500/-
Total 76, 070/-
Hope for your cooperation in the above matter.
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