Oriental insurance company limited, Arbitarily settlement of mediclaim For rs 26395 instead of 43595
Complain ID : JGJN025945 48
Insurance Complaint
Complaint Date : February 4, 2017
- State : Uttar Pradesh
- City : Ghaziabad
- Address: S.E 1/A Shastri Nagar, Ghaziabad, Uttar Pradesh
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
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
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