Oriental insurance company limited, Arbitarily settlement of mediclaim For rs 26395 instead of 43595

Complain ID : JGJN025945   45  

Insurance Complaint  Complaint Date : February 4, 2017
I am continuing medi claim policy no 252106/48/2017/271 from the oriental insurance company limited. Dr suggested me to go for cataract operation with multi focal IOL implant. I went under surgery on 15/12/2016

As per the settlement letter TPA has arbitrarily settled the claim for Rs 26395 instead of RS 43595 citing the reason that” As per reasonable cost & MRP RECORD [As6] is payable up to Rs 10000 /- hence remaining amount is deducted under reasonable & customary Clause of policy & The MRP of unifocal lens which is a medical necessity being paid under policy”

The reason given for the deduction of rs 17000 in the claim is not acceptable as per policy condition.It is no where mentioned in the policy document that the insured is only entitled for Monofocal IOL instead of Multifocal IOL and is entitiled to maximum limit of rs 10000.

Reasonable and customary clause of the policy clearly states that " It is a condition precedent that the expenses incurred in respect of medically necessary treatment, are reasonable and customary; and in any case the liability of the Company shall be upto the limit specified in the policy and/or schedule of the policy, but not exceeding the sum insured as stated in the schedule, for all claims admitted during the policy period mentioned in the schedule. "

I am following up my case with are concerned departments since weeks but so far they have not provided any satisfactory response of my mentioned queries
1) Please let me know the section or page number of attached policy document mentioning the maximum reimbursable limit for IOL implantation
2) Please let me know the condition specifying that only Monofocal IOl implantation instead of Multifocal implantation is covered under insurance policy

This is clearly a breach of trust on part of Oriental insurance company and TPA.
The attitude of TPA and company has caused me tremendous pain and mental harassment.

Hence I have been forced to approach you and request you to help me in getting my balance amount of Rs 17000 incurred on the treatement
Complaint Against / To: Oriental insurance company limited

Reply Now Contact Share

Related complaints

    Service issue | Complaint | Query | Feedback | Suggestion | Reply

    Consumer's reply and reviews

    It's entertains complaints where the value of goods or services paid as consideration does not exceed rupees one crore.

    I am traveling in the bus number 548-DL1PD3568 and the driver and conductor of the bus are misbehaving with the passengers and not stopping at the bus stop.So please I request that the driver and conductor should be taught how to talk to girls at thi...

    Asha

    March 28, 2024

    I have travelling to Mangaluru exp.I am in S4 coach and there are some group of people create very much noise in train which is unbearable in sleeper coach..we need to sleep

    Om parte

    March 28, 2024

    Please Cancel license Of Hotel

    SUNIL RATHOD

    March 27, 2024

    A Vibrant Rant About Onlyfans Pornstars Pornstar Kayleigh Wanless

    Marlene

    March 27, 2024

    Out side House No. 475 Sector 15A, Faridabad, the sewer manhole is over flowing since last more than a week. It is causing health problem to the residents of the house. Some one will have to be admitted to the hospital because of the dirt spread out ...

    CA Ajeet Singh Patwa

    March 27, 2024

    My name mohan add. C2278 sanjay colony bhati mines new delhi 110074 Bus no. DL51EV4243 Route no. 434 My 2 kids and 2 friends are sitting in the bus and the total ticket price will be 10RS but conductor ask to get extra charge and don't issue the tick...

    Mohan

    March 26, 2024

    Model no Rt34c4522BX porchase on Great eastern Sinthee invoice noW1324/2324/20493 dated 21/03/2024 but goods front side scratch and colour faid please replace as soon as possible. Contact no 9804640642

    Suvrabrata Goswami

    March 26, 2024

    Worst service of Flipkart. Support Us

    Palak Jain

    March 25, 2024

    I had booked a season ticket on 5th March ..Payment deducted through UPI ...ticket was visible on first day ..now it's not showing ...transaction history too seemed eraised ..However I still have the traction proof on UPI

    Sneha

    March 25, 2024

    Delhi darwaja bhar near aabkari thana santoshi tample alwar

    Manoj Kumar meena

    March 23, 2024