Originally Posted by Manohar

I have a Individual Health Ins. Policy (Gold Policy) with United India Ins. Co. Ltd., since 2004 and have insured for Rs.1.25 lacs and have been renewing the policy regularly. As I had a block in my heart, I underwent Angioplasty in Dec.2008, I submitted my claim and got reimbursement of a sum of Rs.87,500/- being 70% of sum insured for cardiac surgeries. Unfortunately, I was diognised for 3 blocks and had to undergo Open Heart Surgery on 9th Oct.09 incurring a sum of 1,66,000/-and when I submitted my claim to the TPA of UII Co.for payment of balance amount of my insurance, I recd. reply from them today (12th Dec.09) as under:"We are in receipt of the claim form and associated documents of B.S. Manohar. On scrutiny of the same, we observe that he/she was admitted in BGS Global Hospital. as per policy t & c for major surgical procedure only 70% of si is payable which we have already paid in previous claim with fir no. 806677. In view of the above, we are left with no option but to repudiate your claim. = Sd/- for E Meditek Solutions Ltd." My period of policy was from 12/12/08 to 12/12/09 and it has been renewed further.

Pl. advise me whether the UIIC and their TPA are justified in rejecting my claim and what future course of action to be taken by me. Thanks and regards.

Yes they are justified in rejecting your claim.They pay maximum of 70% for any major illness in a year.In your case its two claims in a year.