discography (none) 29 October 2014

Medical insurance claim denied wrongfuly

Dear Sirs, My wife was admitted in ICU due to high fever. She was in the hospital for 10 days since fever was not reducing. It was diagnoised that fever was due to dental abscess. Medi assist (TPA) denied the claim of Rs. 64000 stating any treatment related to dental issues is not covered. I checked the parent insurance United India insurance website. The clause 4.7 under exclusion states " Dental treatment or surgery of any kind unless requiring hospitalization” . Medi assist agrees that hospitalization was required in this case but here hospitalization means hospitalization due to accidents. However there is no mention of the word "accident in the clause." Please could you let me know what kind of action I can initiate. Also is tort of negligence applicable in this case. IF yes how much damage can I claim . Many thanks Abraham

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Advocate Bhartesh goyal (advocate) 29 October 2014

Your case comes under the purview of deficiency in services of Insurance companyInsurance company can not repudiate your claim when exclusion clause 4.7 is very clear. it is ddeficiency of services.File complaint before District Consumer Redressal Forum having jurisdiction to try complaint and claim ther very clear thatein the expenses incurred for treatment and also claim compensation towards mental and physical agony caused to you.