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cigna ttk health insurance — cashless and reimbursemendenied


Hello, 

My father was admitted to Fortis Hospital Mulund for a disease of Distal Penile Stricture and Proximal Short Segment Bulbar stricture for which the Barbaglis Urethroplasty and EIU cystoscopy surgery was done on   27/03/2019 and the total cost incurred was Rs. 2, 46, 301. I am the Cigna TTK Prohealth Plus policyholder for past 2years which went Claim free, but now when i applied for the cashless before getting my father admitted, they denied the claim a day before saying its a pre existing disease,however the medical tests were done at the time of policy purchase which was initiated by the insurer and no existing diseases were disclosed except Diabetes(which we already disclosed). Post hospitalization, we had provided clarification from our surgeon/doctor as well that patient was unaware about any existing disease and it was only when he diagnosed, the disease was established after seeing certain reports which was done 4days before the surgery.

The Policy inception date is 08/04/2017, and my father suffered with fever and chill which was later suspected to be a UTI infection when we consulted the local doctor on 21/08/2017 (four months after policy purchase and this UTI could be symptom of many another disease so we cannot confidently say that it's  related to the disease for which surgery was done).
We had to arrange the money and pay the money to the hospital somehow and then we contacted a few concerned people from Cigna TTK and they assured us to apply for Reimbursement and it will get processed.
But, now when I applied for reimbursement by sharing all possible required documents from hospital as well as doctor's clarification note, the TPA has again repudiated the claim(possibly the same reason of preexisting disease).
Please help me get my money back as its a very big amount and the patient was unaware about any disease at the time of policy purchase so he did not falsely suppresed the fact.

I looked into the regulation of IRDA for pre-existing disease and it says -If insured had been even otherwise living normal and healthy life and attending to his duties and daily chores like any other person and is not declared as a diseased person as referred above he cannot be held guilty for concealment of any disease. 

Please help me fight this case and suggest the ways to get my money back.



Attached File : 477710 20190412180507 fortis discharge summary part1.pdf downloaded 62 times
 
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senior

approach Insurance Ombudsman

 
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What's their fee and how long do they take to resolve the matter? and also what's their success rate?
 
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Well this has become a regular issue with Insurance companies. They follow up so aggresively on renewals and at times of collecting premiums but the claim settlement ratio is a shock with most of the companies.But do not be afraid to fight against these denials thinking that its not worth with su

Mr.Pratyaksh, I would advice you to first try and settle this issue informally by talking to the senior people in the company and even try to meet them and explain your concern with facts on claim rejection.TWrite an email to the senior level people along with facts and follow up verbally and on Emails too ( so that you have the records to their response in written). If the facts you have presented is really true, the approach MAY change.

If you still experience a negative attitute towards your request, FIRST and Foremost submit a written complaint with supporting documents to the Insurer's Grievance Redressal Officer and follow up to get an acknowledgment with them. You can find their contact details on the policy document and also on their websites.

Simultaneously, you can fill the complaint registration form on IRDA Website and can also write to the consumer affairs department of IRDA. You can also find the toll free numbers whereby you can submit your complain and give reference about the already submitted complaint.

But Yes, before approaching IRDA, it is important to lodge a complaint with Cigna TTK first. Also make sure that your complaint is properly explained with relevant dates and supporting documents and facts.

If you still don't get a resolution or if you are not satisfied, you can approach the Insurance Ombudsman OR file a Civil complain against the Insurer in a Civil Court with the help of an experienced Advocate.

Best Wishes,

Advocate Abhishek Sinha

Mumbai

+91-70459 49997

 

 
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