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Mediclaim issues

(Querist) 03 February 2015 This query is : Resolved 
Respected Attorneys,
My father has a mediclaim policy with National Insurance since 2008..He made a claim only once in 2012 for Kidney stones..The claim was settled as per our satisfaction..Now a few days back he was diagnosed with Glaucoma and had to be operated..He has not even recovered and these Insurance guys have rejected the claim saying : Once the Laser surgery was claimed (the one for Kidney stones) and so another laser one can't be claimed..?? They say that Cataract is covered but Glaucoma isn't covered because it is under Lasik Surgery which is a cosmetic Surgery ??..But it is not mentioned anywhere on the Entire Policy that such an exclusion exists..We have duly paid all the required Premiums etc ..I have no idea about Lasik Surgery..What can be done now? Plz Help..
Harish
Advocate Bhartesh goyal (Expert) 03 February 2015
If your claim does not come under the purview of exclusion clause then Insurance Company is bound to honour your claim.It is not only unfair trade practice of Insurance Company but also deficiency in their services Issue legal notice to Insurance Company and demand your claim along with compensation towards mental and physical agony.If Insurance Company fails to comply with notice than file complaint against Insurance company before District Consumer Forum
Rajendra K Goyal (Expert) 04 February 2015
You should take up the matter with the Insurance Company. If the claim is within norms and not paid, send legal notice and file consumer complaint.
ajay sethi (Expert) 04 February 2015
if insurance company has failed to make payment move consumer forum against company for deficiency in service and seek claim amount with interest and compensation
T. Kalaiselvan, Advocate (Expert) 04 February 2015
A case before the consumer forum for deficiency of service will be a better choice under the given circumstances.
Kumar Doab (Expert) 05 February 2015
Agreed.

Who has declined TPA or Company?

Demand certified cioy of shedule of the company to substabtiate decklinature.

As advised b Mr.Goyal ...The exclusion criteria is published in policy schedule.....

You can escalate complaint to Chairman of the company with a copy to IRDA and approach DCDRF....

You may also go thru Regulation of Protection of Policyholders Interest.


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