I had a corporate mediclaim policy from United Insurance and there third parts administrator(TPA) Vidal Health.Last year in July,I had to undergo a surgey of my jaw bone which was infected,from Apollo Hospital,New Delhi. We had got preathorization for cashless of Rs 50000 initially from TPA based on the CT Scan report submitted by the hospital which clearly suggested the cause of issue was un-errupted teath. At the time of discharge all of sudden I received a message that my claim is rejected.When we enquired from there customer care we got a response that the disease that Hospital has mentioned before hospitalisation is different than stated in Discharge summary.On this our doctor replied them that both the terminology is same and requested them for reconsideration.Also he stated that samples are sent for Biopsy and reports are awaited in 15 days time.In report it was case of Dentigorous Cyst. After few calls with customer care they came up with new theory that its in dental region so it is not covered as per policy.But this is again contradictory to the CT scan report which was submitted before Pre-authorisation,which states clearly that it was a result of un-erupted tooth.So they had committed a mistake which they were now trying to coverup as per my understanding. We tried to arrange a concall from our Doctor with TPA's doctor but TPA's doctor never came up for this. I had raised this issue (Complaint No. - 140868) in Consumer Forum Online,where United Insurance,has expressed again the samething,please refer below the text copied from there reply in Consumer forum:- "The matter was taken up with Regional Office Bangalore and we have been informed that initially the details was shared as PAIN & SWELLING ON THE FACE- ODONTOGENIC TUMOR- SURGICAL EXCISION OF LESION, but when the final bill & discharge summary was received the treatment was purely towards dental, hence the cashless was denied. In view of the above, we treat the grievance as attended to" And then this was reply from consumer forum on 20-April-2017:- Company has responded to your complaint as per their terms and conditions, if you are not satisfied with the company response you may forward your complaint to Insurance Ombudsman , for details you can visit https://www.irdai.gov.in/ADMINCMS/cms/NormalData_Layout.aspx?page=PageNo234&mid=7.2 , following the procedure prescribed by them. I contacted the IRDA Obdusmen as instructed above but they never replied back. Now its going to be 1 year on 7th July 2017 which is the discharge date(or rejection date of claim). Please let me know what should I do.Is there any chance of getting back my money? I stay in Ghaziabad,Surgey happened in Delhi,My headoffice is in Bangalore from where this mediclaim was issued.If I have to file a case where should it be filed?
1) file complaint before consumer forum against the insurance company to pay Rs 50,000
2) enclose copy of medical bills and discharge summary report
3) the insurance policy must contain a clause that in event of dispute claim should be filed within jurisdiction of courts at X
4) file complaint at Ghaziabad if there is no jurisdiction clause in the contract
The online consumer forum cannot go beyond the details submitted by the insurance company which has taken a stand to reject the claim based on the doctors report/opinion. The TPA doctor also will not be generous enough to apply his mind because he is again an employee of the organisation hence he has to be faithful to his employer.
The Insurance ombudsman also has limitations beyond which it is toothless.
You have file a complaint with the district consumer grievances redressal forum seeking justice, compensation for deficiency of service and recovery of insurance amount.
You can produce the entire medical details and records while convincing the consumer forum, let the insurance company with with their own opinion, you can fight them on merits in your side.
1.Running around the IRDA would not give any result as it has regulatory function on insurance companies but it can not adjudicate the dispute.
2.if you don't get proper remedy or your grievance is not redressed by the Insurance Company you can file case before the consumer forum.
3.The consumer forum is quite harsh on the unfair trade practice of the insurance companies and would get you award of damages,compensation and compliance of insurance policy.
Good luck.
