AS AGAINST:

1. M/s. Reliance General Insurance Co. Ltd., 3. M/s. Reliance General Insurance Co. Ltd.,
Being rep. by it’s Managing Director, rep. by it’s Corporate Manager,
Head office situated at 5th Floor, Corporate office situated at 570,
NKM International House, Naigum Cross Road,
128 Backbay Reclamation, Next to Royal Industrial Estate,
Babu Bhai Chinai Road, Wadala (W), Mumbai – 400 031.
Mumbai – 400020.

2. M/s. Reliance General Insurance Co. Ltd., 4. M/s. Reliance General Insurance Co. Ltd.,
Being rep. by it’s Authorized Manager, Rep. by it’s Branch Manager.
Regd. Office situated at Reliance Centre, 403, Eswar Paradise,
19 Walchand Hirachand Marg, Dwaraka Nagar Main Road,
Ballard Estate, Mumbai – 400 001. Visakhapatnam – 530 016.

Particulars of the complaint:

1. I am the policy holder of the opposite party’s Med Assist policy, bearing No. 1802/282510323351 and MAID No. 400810230, under silver plan, having joined the same in the month of December, 2008. Due to my misfortune, I got problem for my ear in the month of February, 2009 and was given treatment by Dr. M.D. Prasada Rao, a reputed ENT specialist at Visakhapatnam. In spite of administration of antibiotics and other drugs as advised by the said doctor, the problem is not rectified. As such, during my visit to the said doctor on 06-05-2009, I am advised surgery of ‘‘Mastoidectomy with tympanoplasty’ for my ear for the said problem, i.e., ‘Otitis media with Cholostectoma’.

2. Since I am the policy holder of the opposite parties, I requested the doctor to conduct the said surgery at one of the net work hospitals of opposite party and as he consented for the same, on 07-05-09, I approached M/s. Bharathi Hospital, Maharanipeta, Visakhapatnam, which is their net work hospital and got filled all the required forms, as instructed by the net work hospital. After processing all the required documents, the said hospital gave a pre authorization Number, i.e., 4045431 and I also received a message over my mobile from the opposite party’s company to that effect stating that the issue is under process. Later, I also received another message over my mobile to submit I.D. proof and previous case sheet. Though I already submitted my ration card towards identity proof on 07-05-2009 itself, as per the instructions over the toll free number of the insurance company, I also submitted my voter’s identity card towards proof of identity, together with my previous case sheet dated 04-02-2009 and the test reports, got conducted by my doctor, under the said prescription. All the said documents were again processed to the insurance company through their above mentioned net work Hospital.

3. But, to my utter surprise, I received a message over my mobile on 15-05-2009, stating that ‘cashless declined. Please pay & submit for possible reimbursement’. I again contacted the opposite party over their toll free number and was informed that there was a mention in the prescription of my doctor that the ear discharge is in existence since one year and as such cashless facility is declined. I rushed to my doctor and got clarified that no where in his case sheets such words appear. I am made to under stand that the opposite party is unable to under stand the hand writing of the said doctor in the prescriptions dated 04-02-09 and 06-05-09 and mistaken the word ’PYREXIA’ as ‘1YEAR’, which was clarified to the insurance company by the said Dr. M.D. Prasada Rao from his clinic, during his conversation with Mr. Vishal over the toll free number on 16-05-09 at about 12 noon. As per the instructions of Mr. Vishal, he issued a letter to that effect confirming that the particular disease is not in existence for the past one year and no where in his prescriptions, it was written like that. As asked by the said Mr. Vishal, the said doctor has also issued attested prescriptions in the printed form for his hand written prescriptions dated 04-02-09 and 06-05-09, which were forwarded to the insurance company by Fax through Bharathi Hospital in the after noon of 17-05-09. I also sent number of mails to the mail I.D. of the opposite party and has been corresponding with one ‘Vanajakshi bm’ requesting for an early response in this matter, in order to avoid further complications. But, since 17-05-09, the opposite party has been silent and not giving any response to me.

4. I also sent a mail to the opposite party to that effect to rgi@mediassistindia.com on 18-05-2009. But, in spite of all the clarifications, she received mail from the authorized correspondent of the opposite party, through Vanajakshi BM on 19-05-2009, <vanajakshibm@mediassistindia.com>, denying the claim stating the reason that the consultation paper dated 04-02-2009 shows H/O ear discharge since I year. Again I contacted through their toll free number and as it was expressed that the said clarification letter was not seen by them and again as per their instructions, I mailed another letter on 20-05-2009 to rgi@mediassistindia.com & Vanajakshi BM <vanajakshibm@mediassistindia.com>, attaching to it the prescriptions dated 04-02-2009 & 06-05-2009, printed forms of attested prescriptions and the clarification letter of the doctor, with a request to sanction cashless facility to me for which I am entitled under the policy. Later on, I have also sent two mails to the opposite party on 22-05-2009, at 2-48 p.m. & 4.05 p.m., to rgi@mediassistindia.com & Vanajakshi BM <vanajakshibm@mediassistindia.com> and also contacted them over their toll free number expecting a positive response, but, of no use.

5. My doctor advised that if the surgery is further delayed, the infection may spread up to the Brain and hence, I got conducted the above surgery on 27-05-2009, at Gayatri Nursing Home, Near Zilla Parishad, Visakhapatnam, which is very near to my parents’ residence. I am discharged on 28-05-2009 from the said hospital and underwent treatment as an out patient.

6. After the surgery also, I contacted the opposite party over the toll free number 180030028282 on 31-05-2009, informing about the surgery, which was conducted on 27-05-2009 and they instructed me to send all the original prescriptions, medical bills and original test reports together with duly filled claim form to their registered office, so as to enable them to pay the claim amount within 30 days, as prescribed under the policy. Accordingly, I have sent all the original documents in the month of June, 2009, as detailed below, by regd. Post with acknowledgement due, with a request to pay me Rs. 15,745/- towards the claim amount, as per the bills sent to them.

List of original documents sent by me to the opposite party in June, 2009:

S.No. Date Description of document

1. 04-02-2009 Prescription of Dr. M.D. Prasad Rao(already sent by Fax)
2. 04-02-2009 Receipt for Rs. 300/- of Gowthami Diagnostics.
3. 06-05-2009 Prescription of Dr. M.D. Prasad Rao(already sent by Fax)
4. 16-05-2009 Clarification letter issued by Dr. M.D. Prasad Rao,
together with attested printed form of prescriptions.

5. 18-05-2009 My client’s request letter sent by E-Mail, to
rgi@mediassistindia.com

6. 19-05-2009 Your letter dt. 19-05-09, from your authorized correspondent, through Vanajakshi BM <vanajakshibm@mediassistindia.com>,
denying the claim

7. 20-05-2009 My client’s request letter dated 20-05-2009 together with attachment of all the prescriptions and clarification letter issued by the doctor, sent through E-Mail to rgi@mediassistindia.com & Vanajakshi BM <vanajakshibm@mediassistindia.com>


8. 27-05-2009 Cash Bill for Rs. 1,000/- of Seetha Medical Stores.



9. 27-05-2009 Cash Bill issued for Rs. 274/- of Seetha Medical Stores.


10. 27-05-2009 Cash Bill issued by Chaitanya Medical Centre.
11. 28-05-2009 Receipt issued by Gayatri Nursing Home, for Rs. 3,000/-
12. 28-05-2009 Receipt issued by Dr. B. Murali Krishna,
Anaesthesiologist, for Rs. 1,500/-
13. 28-05-2009 Discharge Sheet issued by Gayatri Nursing Home.
14. 29-05-2009 Receipt issued by Dr. M. D. Prasad Rao, for Rs. 8,500/-
15. 29-05-2009 Cash Bill for Rs. 103/-, of Seetha Medical Stores.
16. 03-06-2009 Cash Bill for Rs. 818/- of Sagar Durga Drugs

7. Having received all the originals at their registered office at Mumbai, under regd. Post with acknowledgement due, vide RL No. 4622, dated 11-06-09, which was received by the opposite party on 13-06-09, as per the postal acknowledgement received from it. As there is no response from the opposite party, I addressed a Regd. Letter dated 22-09-2009, requesting the insurance company to pay my claim amount by way of D.D. payable at Visakhapatnam, as per my letter dated 11-06-09, at the earliest. Though the insurance company is bound by the policy to pay the claim amount within 30 days, in spite of my reminders, there is no response from their end.

8. I submit that under the terms of the Med Assist policy of the opposite party, I am entitled to provide cashless facility. I am unable to under stand what is meant by the insurance company for ‘possible reimbursement’, when I approached their net work hospital, but not the hospital of my choice. As could be understood by me through their agents and also through the terms of the policy, reimbursement facility will be provided for urgent surgeries, when there is no opportunity to process the case in advance. But, having processed all the documents in advance and having clarified all their objections, I could not understand what prevented the opposite party to decline cashless facility. But, however, due to their delayed tactics, I am compelled to undergo surgery at some other hospital and submitted all the original bills, prescriptions and test reports, as instructed by the opposite party. But, so far, there is no response from them. In spite of my personal visits to the local office, which is the branch office at Visakhapatnam, no redressal has been extended, except postponing the issue.

RELIEF SOUGHT FOR:

Therefore, it is requested to guide me to get the following reliefs as against the opposite parties:

(a) to receive the claim amount of Rs. 15,745/- to me, together with interest at 24% p.a., from the date of the surgery till the date of realization and

(b) to receive compensation to me for the mental agony and distress caused to me, due to the delay, inaction and silence of the opposite parties.

Thanking you,

Yours faithfully


VURITI VIJAYALAKSHMI