Not satisfied with irda resolution for my mediclaim

My mother Mrs C. Umarani was hospitalized on 01-Mar-2012 at Gem Hospitals, Coimbatore for Ventral Hernia. The Policy is Goodhealth Group mediclaim policy by The new India Assurance company provided through citibank cards and the TPA is TTK Health services Ltd.

 

The request for cashless hospitalization was rejected on 2-Mar-2012 with reason "This ailment not payable in the second year of taking the policy". However the second continuous policy year was over on 29-Feb-2012 and the claim must be admitted from 01-Mar-2012 as per the insurance contract entered with me by the New India Assurance company.

 

On taking up this breach of contract with TTK who are the TPA of the insurance company, i was advised by TTK helpline to settle the bills and claim the amount which is for a total of Rs 59,769. I settled the bills with Gem Hospitals and my mother was discharged on 04-Mar-2012. I submitted the all the original documents pertaining to the claim to TTK through courier, and they acknowledged its receipt on 9-Mar-2012 over phone.

Again, the TPA has further denied the claim that the ventral hernia is a result of a pervious surgery done. However the previous surgery was done during child birth about 30 years ago and she was not having any side effects due to it . This is unfair way of rejecting the claim . Further the current treating surgeon did not anyway mention that the current ventral hernia is a only due to complication of a surgery done about 30 yrs ago.

 

I have also recieved a letter from  New India Assurance company stating the same reason as given by IRDA. However on going through the policy clause 1.1f which states "In respect of specified ailments, company's liability in respect of each and every claim, as arrived at under the table of benefits given, and admitted during the period of insurnce, subject to policy terms, conditions and exclusions, shall not exceed the limits mentioned against the respective specified ailment Or the sum insured available for the insured person, whichever is less: Table: Disese( The expenses incurred on treatment of the specified diseases are payable only after completion of a continuous period of insurance under our good health mediclaim policy as specified against each disease) : Hernia, Period for which claim not admissable: 2 years, Limits per claim: 20% of sum insured. 

However It did not specify that the disease should not have been contracted during second year, it talks only about claim being admissable from third year, which i have done. However the insurance company interprets the clause in such a way that if the disease is contracted in second year it cannot be paid in third year also, which is unfair and not mentioned in the contract clearly and is open to different interpretations.

Also so far they have stated various reasons contrary to the insurance contract entered with me to dispute my claim which shows that their motive is to hassle me. I therefore plan to claim the higher of Rs 20000 or the limit prescribed by IRDA if any, for the mental agony cost to me by the TPA and insurance company along with original claim amount with interest.

I request experts in dealing with insurance to guide me in this issue and suggest me a suitable course of action next. If my pleading has valid legal standing, i also require legal services from lawyer with insurance specialization. 

Thanks for your time and expecting your valuable suggestions.