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Refusal of Mediclaim policy by TTK Healthcare TPA Ltd

This is a discussion on Refusal of Mediclaim policy by TTK Healthcare TPA Ltd within the Medical Insurance forums, part of the Insurance category; Dear Sir/Madam, My father who is 66 years and lives in Mumbai was recently diagnosed with cancer on the base ...

  1. #1
    paragsoni is offline Junior Member
    Join Date
    Oct 2010
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    1

    Default Refusal of Mediclaim policy by TTK Healthcare TPA Ltd

    Dear Sir/Madam,

    My father who is 66 years and lives in Mumbai was recently diagnosed with cancer on the base of the tongue. He was admitted to Prince Aly Khan Hospital, Mazgaon, Mumbai under the treatment of Medical Oncologist Dr B Dabur. On discharge from the hospital, he submitted claim for mediclaim policy to TTK Healthcare TPA Ltd.

    On 27/09/2010 he received a letter from TTK and I copy the excerpts:

    WITHOUT PREJUDICE

    Policy Number: 111800/34/09/11/00014880
    Claimant: Harkishan V Soni
    Policy period: 24/12/2009 to 23/12/2010

    • The said patient was admitted to PRINCE ALY KHAN HOSPITAL on 01/09/2010 and discharged on 06/09/2010 for treatment for SQUAMOUS CELL CA BASE OF TOUNGE.
    • As per Medical Discharge card, claimant has habits of Tobacco & pan chewing for more than 25 years and smoking since 10 years which are the complications of present ailment. Hence we are unable to settle your claim.

    Therefore, as per the terms and conditions of mediclaim policy this claim is rejected under Clause 4.4.6 which states as below:

    “The company shall not be liable to make any payments under this policy in respect of any medical expenses incurred or arising out of convalescence, general debility, 'Run-down condition or rest cure, Obesity treatment and complications, congenital external disease / defect or anomalies treatment relating to psychiatric and psychosomatic disorders, infertility, Sterility, use of intoxication drugs, alcohol, use of tobacco leading to cancer.”

    In view of the above facts, we regret the claim is not payable.

    Questions:

    1) Can they infer from the patient's 'dischage card' that the use of tobacco caused the cancer? Do they have legitimate grounds to refuse the claim?
    2) Do we have grounds to appeal? If so, are there usually any time limits?

    Many thanks for your help.

    Regards
    Parag Soni

  2. #2
    Raviprakash is offline Senior Member
    Join Date
    Jan 2010
    Posts
    131

    Default

    Dear Parag,
    PLEASE NOTE THE FOLLOWING POINTS

    Tobacco chewing is not the only cause of cancer. Squamous cell Ca of tongue has been seen even in patients who never used any form of tobacco. What medical reasearch says is that there is association between any form of cancer and the use of tobacco so much so that a cause and effect relationship can be attributed to the use of tobacco and cancer.

    In the light of this background I want induce you into thinking in these lines.

    If tobacco did cause Ca tongue, why there are so many people dead or alive who never had Ca tongue after the use of tobacco?
    Whether tobacco is the only cause for Ca tongue? Why Ca tongue is seen in people with no history of use of tobacco?
    IN other words the other causes of Ca tongue such as a 'Sharp tooth', Bad oral hygiene, heriditary factors and food items which can cause a cancer so much so the cause of cancer has not been fully established as yet. There are only some associations that's all.

    Coming to the law point,
    The policy period is 24/12/2009 to 23/12/2010. The date of operation is between 1/9/2010 and 6/9/2010. Now what is the contention of the Insurance Company, whether it says that there was no cancer at the time of issuing the policy on 24/12/2009 and it appeared only after that date? I mean to say that cancer could have been in the intial stage even at the time of issuing the policy which no one can ascertain now by any stretch of imagination. What does the insurance company say about the smoking habit of its insured at the time of issuing the policy? Did it gave the policy to a person who is predisposed to cancer? Even in such situation the onus of proving the clause " use of tobacco has lead to this cancer in this particular person" squarely lies with th company which is highly impossible for them.

    Therfore I am of the opinion that if you catch hold of a reasonably good lawyer, and present your case properly your district consumer court should be able to entertain your complaint and deliver favourably to you. There is a good possiblity that soon after you send a legal notice, they will arrange to pay your claim.

    All the best.

    Dr. Raviprakash 09448120373

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