Bajaj Allianz Life Insurance Company Ltd/ MEDICARE TPA SERVICE PVT. LTD.: Complain against claim settlement

Dear Sir,
I have taken a health policy from Bajaj Allianz Life Insurance Company Ltd (Family CareFirst) last year and I have submitted a file with all the documents for claim (For my son who got injured while playing in school and had a deep cut in side the lower lips and had a six stitches and was under observation for 24hrs.) of a medical insurance of amount 3219=50 at MEDICARE TPA SERVICE PVT. LTD., alkapuri, vadodara on 24th July, and i have received a cheque of Rs 1739=00 on 3rd oct.2009 (1774=81 amount was settled against my claim of Rs 3219=50), with “cash sheet” having some detail (see the 1st attachment). but I was not cleared that why I am getting only this much amount (1739=00 against claim of 3219=00) and why they have send me a cheque of 1739=00 against the settled amount 1774=81Rs).

To know this I have written a mail with my query (with one separate sheet containing details of what i had claimed and what they have settled in tabulate form, (see the 2nd attachment ) to bajajallianz and MEDICARE TPA SERVICE and also submitted an application to both but till date I have not received any call or message form MEDICARE TPA SERVICE, so I forced bajajallianz to reply me (as I have taken policy form them and paying money to them).

After that I have received a call from one of your member of bajajallianz (ph. no.: 02030514756, at 12:26pm, 2nd November), he had informed me that " the amount you have received i.e. 1739=00 is ok against your claim of Rs. 2958=00". He even didn't know the reason for why, and not having any answer of my query. Infect he doesn't know about how much i have claimed (3229=50) and what amount they have settled (1774=81). Again I forced them to reply in mail but in reply they send me the same “cash sheet”, which they have send me with cheque, and a sentence “Please find enclosed soft copy for your ready reference”. In reply of this I wrote them to give an explanation but they had send me the same sheet with a sentence “As the same was already explained to you regarding the claim status & amount. Also check the attachment of the same”. This was their last reply on 26th Nov. then after they are not giving any reply of my mails.

I discussed with my agent and according to him they have calculated the Consulting fees (300Rs, Operation charges (1500Rs) and Dressing (100Rs) as a physician, surgeon charge/fees (total 1900Rs) and as per policy (doctor’s fee Maximum 25% of the total medical expenses incurred on in-patient treatment) they have given 25% of 1900rs. i.e. 734=962Rs.

But actually how they can consider operation charges and dressing charges as a doctor’s fee, as it include Cost of Anesthesia, Medicines and Drugs, Surgical Appliances, any disposable surgical consumables, etc., if they calculate that way then no body can get the full amount (i.e. 95% ) of claim, and we can show the policy to doctor and tell them to make bill according to policy !!! All and all they are cheating to customer.

So sir my complain is against bajajallianz life insurance Company Ltd. and/or MEDICARE TPA SERVICE PVT. LTD. that they are making fool of customer by not giving any explanation on settling amount and miscalculating the claim amount, as I have explained you, and settling less amount of claim.
Sir, kindly requests you to look after into this matter and solve my problem and help me in getting remaining amount of claim.

Attached: (separately sent through email on <admin@consumercourt.in>)
1) Case sheet
2) Queries (In tabulated form)
3) family care first brochure

regards
Jiten Patel