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Jainantony Antony   13 June 2020

mediclaim policy coverage

my friend was under the coverage of the mediclaim insurance policy for the last 2 years.but two weeks ago he suffered a stomach pain and consulted a doctor in nearby hospital.after scanning it is revealed that some tumours are in his stomach and suggested emergency operation. these facts informed the TPA of the insurance company. after considering these facts they have rejected the cashless facility .pointing that the disease was pre existing one.but the fact is that the patient was aware about his illness only after facing the stomach pain.but considering the emergency the patient paid expenses from his pocket ie around 1.5lakhs.In this situation what remedy is available to him to realise his treatment expenses kindly let me to know the remedies


 4 Replies

Sampada Sharma   13 June 2020

You can go to Consumer Disputes Redressal Forum for the reimbursement of your expenses of 1.5 Lakhs from the Insurance Company. Under the policy, after 2 years of the policy major Diseases was covered by the Mediclaim Company, and Tumour is not a kind of disease which can be kept hidden or anyone can wait for 2 years fotr the treatement.

Hope you get your answer. Have a nice day.

G.L.N. Prasad (Retired employee.)     14 June 2020

First submit the entire bills demanding for immediate reimbursement.

Let them reject the bills stating the reasons.

Then issue a notice through advocate making counter that the rejection is not legally valid.

Then make a complaint to Insurance Ombudsman and IRDI

Let this process continue for 6 months without spending an additional rupees.

After six months file Consumer complaint.

All this in good faith that the pre existing condition was not suppressed and policy was taken without knowing such ailment in advance.

P. Venu (Advocate)     14 June 2020

Has your preferred tha claim? If rejected, take up the matter with the Insurance Ombudsman. The Ombudsman can take into account equitable considerations while deciding the dispute. For the purpose of an insurance claim, a desease can be said to be contracted only when it is diagnosed by a competent physician and confirmed. 

Dr J C Vashista (Advocate)     14 June 2020

You are required to submit your claim with relevant bills, prescripttions and discharge certificate with a copy of policy for reimbusement.

If it is declined / rejected move to consumer disputes redressal fora of jurisdiction.

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