• Repudiation/rejection of mediclaim By oriental Insurace company.

I have a family floater mediclaim policy of oriental insurance company,i have submitted claim of my self male 44yrs for occulsion and stenting of carotid artery .in the month july 2019. the claim is rejected on following ground by insurance company as under:

letter content of insurance policy as under:
You have submitted a claim for Occlusion and Stenosis of Carotid artery and underwent surgical management neuroangiography with P Plasty of right carotid artery with stents for the same. As per available details with us, you are a known case of Diabetes Mellitus since 5 years. It is observed that your policy is with us since 01/06/2017 till 31/05/2020. The claim is in 2019-20 policy which means that the claim is in third year of policy and not completed 3 years.
Therefore the claim is repudiated and not payable under our Policy condition no. 4.1 which states that - All Pre-existing Diseases (whether treated / untreated, declared or not declared in the Proposal Form), are excluded upto 36 months of the Policy being in force and shall be covered only after the Policy has been continuously in force for 36 months. For the purpose of applying this condition, the date of inception of the first PNB-Oriental Royal Mediclaim shall be considered, provided the Renewals have been continuous and without any break in the policy period. This exclusion shall also apply to any complication(s) arising from Pre existing Diseases. Such complications will be considered as part of the Pre existing health condition or Disease. 
Since your policy has not renewed continuously without break for 36 months, the claim is repudiated and is not payable.
letter of insurance company ends here.

But above medical condition has nothing to do with my existing or preexisting disease,now 
my question is as below:
what is the next procedure for the above?
what is the merits of the case in case i have to fight in courts?
thanking you
vikram rathi.
Asked 1 year ago in Civil Law

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9 Answers

you can file claim before consumer forum against repudiation of your insurance policy 

 

2) you have suppressed material facts about your illness and is ground for repudiation of claim 

Ajay Sethi
Advocate, Mumbai
80564 Answers
4945 Consultations

5.0 on 5.0

the following are the reasons given by the insurer for rejection of your claim

a. the medical condition for which you underwent surgery is a result of your pre-existing disease - that is the heart condition is a result of diabetes and therefore stands excluded. 

b. the pre-existing disease and complications arising from it are not covered upto 3 years from beginning of policy. Since your policy has not yet completed 3 years, the claim is not covered

c. the policy was required to be in force for continuous period of 3 years. That is the policy must not be lapsed in between due to non payment of renewal premium. The insurer says that your policy was not continuously in operation since it had lapsed in between

 

for the above reasons your claim is rejected

the contract will have to be studied to understand the other clauses 

without seeing the contract it is not possible to further advise

if the claim is wrongly rejected then you will have to challenge it before the competent tribunal or if there is any arbitration clause then by invoking that clause

Yusuf Rampurawala
Advocate, Mumbai
5916 Answers
43 Consultations

5.0 on 5.0

Non-disclosure of ailments can lead to trouble. You may have pre informed about Diabetes Mellitus ?? Nexus is important factor between present and previous decease.

File claim before consume court.

Yogendra Singh Rajawat
Advocate, Jaipur
21422 Answers
31 Consultations

4.4 on 5.0

You need to file a case before consumer court in the same for deficiency of service. You will get remedy early

Prashant Nayak
Advocate, Mumbai
23004 Answers
49 Consultations

4.4 on 5.0

dear sir pls approach the Consumer court as there is deficiency in services on the part of the insurance company.

Anwar Zaidi
Advocate, Mira Bhayandar
231 Answers

4.5 on 5.0

You should send them a legal notice for paying the claim amount along with interest with in 15 days through your advocate.

If they refuse to refund the claim amount within notice period you should initiate a complaint in consumer forum for refund of money along with interest and compensation for harassment suffered due to repudiation of claim. 

Merits of case are in your favour because the burden of proof will be on insurance company to proof there case and produce documents of your medical history.

Mohit Kapoor
Advocate, Rohtak
10685 Answers
7 Consultations

5.0 on 5.0

See they have wrongly repuidated your claim on ground of pre-existing issue take medical expert opinion that your pre-existing condition has nothing to do with surgery and then file a consumer complaint seeking claim amount and compensation. 

Shubham Jhajharia
Advocate, Ahmedabad
25521 Answers
125 Consultations

5.0 on 5.0

You can file a consumer complaint against the insurance company before the consumer forum. But to provide appropriate opinion, all the policy documents and the correspondences exchanged with the insurance company, if any, need to be looked into in totality. 

Mohammed Mujeeb
Advocate, Hyderabad
18991 Answers
15 Consultations

4.5 on 5.0

This is the usual tactics adopted by the insurance companies for repudiating the claim especially when they do not want to pay the claims.

This is a clear case of deceit.

You can very well issue a legal notice first to the company seeking your claim amount, let them give a reply denying the claim, after that you can approach consumer forum with a complaint.

You will certainly get justice through consumer court which will include compensation besides claim amount.

T Kalaiselvan
Advocate, Vellore
70617 Answers
986 Consultations

5.0 on 5.0

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