Dear sir / Madam

I am insured under mediclam insurance policy of New India Assurance Co. Ltd whose TPA is Raksha TPA Pvt. Ltd.

I was hospitalised from 31st October,2010 to 03rd November, 2010 whose documents for claim settlement were submitted in the office of TPA. After talking to them many times and even going personally several times, i am not getting any responsible answer from there. Every time I am told that your claim will be settled shortly.But after a time span of 7 months till today I am not assured that my claim will satteled or not.

Insured Name Patel Rameshbhai Prabhudas

Policy no. 112500/34/10/11/00012074


Then finally on 24 december 2010 I got one letter from the TPA that your claim is NON TANABLE for reason (Reason : We have received your claim documents. As per documents available, patient was admitted in hospital with the complaints of LEFT CEREBELLAR TUBERCULOMA WITH LEPTOMENINGEAL ENHANCEMENT IN LEFT PARASAGITTAL, FRONTOPARIETAL REGION. Patient was admitted admitted for evaluation purpose only without active line of treatment. Hence, this claim stands repudiation under clause 4.4.11.

Clause 4.4.11:- Diagnostic, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home. LEFT CEREBELLAR TUBERCULOMA WITH LEPTOMENINGEAL ENHANCEMENT IN LEFT PARASAGITTAL, FRONTOPARIETAL REGION)

This reason is baseless the we don’t go for any active line treatment. At that sudden point of we follow all the instruction by medical staff of concern hospital.

I have letter from hospital regarding the same. In discharge card its clearly mentioned that
1) Papatient was referred from private nursing home.
2) Weakness of leftside of body.
3) Fever since last night

So I am requesting you to please help me out to get justice in particular case.

Attachment :

1) Claim form
2) Letter from hospital
3) Complaint letter
4) Letter from consulting physician.

Sir, this kind of attitude is not expected from an Esteemed Co. like them.
I hope I'll get some help through your forum.

Policy Details of :Patel Rameshbhai Prabhudas
Policy Information
Insurance Co.Name The New India Assurance Co. Ltd. Corporate Name Individual
Proposal Date 24-NOV-2010 Policy No 112500/34/10/11/00012074
Policy Start Date 24-NOV-2010 Employee No
Policy End Date 23-NOV-2011 Raksha ID No N9011433028
Agent Code 833/88689 ID Card Status Renewal Letter Issued
Endorsement Date Endorsement No
Insured Name Patel Rameshbhai Prabhudas Address Room No-1, Ramshran Yadav Chawl, Shivaji Nagar Village Malad [E], Mumbai Dist. : Greater Mumbai, Maharashtra_400097
Photo Status Photo Not Received 64 VB Satus 64 VB Received
Insurance Coverage Rs. Coverage Type
E-Mail ID NA
Click here for
Print E card
Claim Detail
Cashless Information
Complaint Regarding ID Card

Insurance Details
Name of the Insured Relation with Insured Age Amount Covered
Patel Rameshbhai Prabhudas Self 44 120000
Patel Niruben R. Wife 43 115000
Patel Kinjal R. Daughter 22 120000


CLAIM STATUS

Claim No. 9021011115495
Memberid N9011433028
Unique Policy Number 112500/34/09/11/00011432
Insured Name Patel Rameshbhai Prabhudas
Patient Name Patel Kinjal R.
Relation Daughter
Admission Date/ Discharge Date 31-oct-2010 / 03-nov-2010
For the Treatment of LEFT CEREBELLAR TUBERCULOMA WITH LEPTOMENINGEAL ENHANCEMENT IN LEFT PARASAGITTAL, FRONTOPARIETAL REGION
Hospital Name Kokilaben Dhirubhai Ambani Hospital & Medical Research Centr - null
Claim Received Date 22-NOV-2010
Claim Amount Rs. 57246/-
Document Check List
Claim Processing Date
Reason for NonPayable: We have received your claim documents. As per documents available, patient was admitted in hospital with the complaints of LEFT CEREBELLAR TUBERCULOMA WITH LEPTOMENINGEAL ENHANCEMENT IN LEFT PARASAGITTAL, FRONTOPARIETAL REGION. Patient was admitted admitted for evaluation purpose only without active line of treatment. Hence, this claim stands repudiation under clause 4.4.11.

Clause 4.4.11:- Diagnostic, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home. LEFT CEREBELLAR TUBERCULOMA WITH LEPTOMENINGEAL ENHANCEMENT IN LEFT PARASAGITTAL, FRONTOPARIETAL REGION
Cheque No./ Amount No Cheque Number / 0
Deduction: NA,
Despatch Date/Courier Name (Latest Despatch Details)