Mediclaim reimbursement not being given
Querist :
Anonymous
(Querist) 28 February 2011
This query is : Resolved
My husband died of cancer about 6 months back. He underwent treatment/hospitalisation in AIIMS for just about about two months prior to his death. Before dying he applied for reimbursement of medical expenses as he had a mediclaim policy. The TPA company has been informed of his death but inspite of knowing of his death twice they have sent cheque in my husband's name for half the the claimed amount, which have been returned as his bank accounts have been closed down. Moreover they are not reimbursing full claimed amount (Rs. 20000.00 only) I am feeling harrased by the TPA/Insurance company for last six months. Where can I go in south delhi area to complain against them or file a case against them. For this small amount I cannot pay a lawyer's fee.
Devajyoti Barman
(Expert) 28 February 2011
You can file a case for damages under Consumer Protection Act in the place where you are currently staying if the Insurance Company has a branch office at that place.
A V Vishal
(Expert) 28 February 2011
First approach the Insurance Ombudsman with your grievance, the claim will be settled favourably, you can approach directly without any advocate with your complaint.
The address of the ombudsman for Delhi region is:
Insurance Ombudsman,
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Bldg.,
Asaf Ali Road ,
NEW DELHI-110 002.
Tel.:- 011-23239633
Fax : 011-23230858
Email iobdelraj@rediffmail.com
A V Vishal
(Expert) 28 February 2011
Power of Ombudsman
Insurance Ombudsman has two types of functions to perform (1) conciliation, (2) Award making. The insurance Ombudsman is empowered to receive and consider complaints in respect of personal lines of insurance from any person who has any grievance against an insurer. The complaint may relate to any grievance against the insurer i.e. (a) any partial or total repudiation of claims by the insurance companies, (b) dispute with regard to premium paid or payable in terms of the policy, (c) dispute on the legal construction of the policy wordings in case such dispute relates to claims; (d) delay in settlement of claims and (e) non-issuance of any insurance document to customers after receipt of premium.
Ombudsman's powers are restricted to insurance contracts of value not exceeding Rs. 20 lakhs. The insurance companies are required to honour the awards passed by an Insurance Ombudsman within three months.
Manner of lodging complaint
The complaint by an aggrieved person has to be in writing, and addressed to the insurance Ombudsman of the jurisdiction under which the office of the insurer falls. The complaint can also be lodged through the legal heirs of the insured. Before lodging a complaint:
i) the complainant should have made a representation to the insurer named in the complaint and the insurer either should have rejected the complaint or the complainant have not received any reply within a period of one month after the concerned insurer has received his complaint or he is not satisfied with the reply of the insurer.
ii) The complaint is not made later than one year after the insurer had replied.
iii) The same complaint on the subject should not be pending with before any court, consumer forum or arbitrator.
adv. rajeev ( rajoo )
(Expert) 01 March 2011
Issue notice to the ins., co., to settle the mediclaim. Definately they will keep quiet then file a consumer case.
G. ARAVINTHAN
(Expert) 01 March 2011
Complaint before the Consumer disputes Redresall Forum for compensation
Guest
(Expert) 01 March 2011
I agree with Vishal and Barman. Lodging a complaint with Consumer Forum is not a costly affair.
So, your first step should be to approach Insurance Ombudsman. I am sure you can get justice from Ombudsman and may not need to go the the Consumer Forum. However, if Ombudsman also fails to do justice, your second step should be to approach Consumer Forum.
PS Dhingra
Chief Executive Officer
Dhingra Group of Management & Vigilance Consultants
New Delhi-110089
Mobile: 09968076381
[dcgroup1962@gmail.com]
