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Jayanta (Service)     11 June 2014

Legal advise on mediclaim

I have been undergoing chemotherapy treatment for expensive but non-curable treatment of blood cancer; I am covered under Company's Mediclaim scheme with New India and TPA is Medi-Assist. Annual cap is Rs.2 lakhs. Advance was made in Dec 2013 and Medi-Assist Noted it ; when I submitted Final Claim Bill on 18.3.14, since then they remain mute and after a marathon follow-up, after 3 months they now mention about non-availability of floater policy & exhaustion of Rs.2 Lakhs cap in 13-14. My Q is that I had intimated them before admission and they did not object. They could have comfortably processed the claim in FY 14-15, as promised to me and it is a continuing policy over 10 years. Now, I cannot take forward this claim for submission to National Insurance Co. Ltd, where I have been maintaining a second policy out of my taxable income. This May, I have missed out my scheduled admission . But inspite of escalation and repeated prayer, Medi-Assist is not replying. They had earlier refused cashless facility as well. My annual expenditure runs in to Rs.10 Lakhs upwards and due to unmatched income, my treatment goes for a toss. I had taken it up with Ombudsman but no result so far. SIR, KINDLY ADVISE ME HOW TO PUSH THE CASE AT MEDI ASSIST WITH LEGAL JUDGEMENT. REMAIN GRATEFUL.Regards, Jayanta Bandyopadhyay 11.06.2014


 2 Replies

Rama chary Rachakonda (Secunderabad/Highcourt practice watsapp no.9989324294 )     11 June 2014

While buying a mediclaim policy, you should look if there are any limitations on certain specific treatments. At times insurers levy limits on certain specific treatments, like, cataract, cardiac treatments, etc. - It is necessary that you go through the terms and conditions of the policy. This helps in getting in depth knowledge about the entire policy.

Sunil S Nair (lawyer)     12 June 2014

If you can proof all the facts you sated in query wait for decision from bank ombudsman and then file a petition in consumer court with relief sort 

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