Complaint Details

Status	:	Closed
Complaint No	:	0052010/2015
Category	:	Insurance
Date	:	12-06-2015
Subject Line	:	Claim rejectection
Complainant	:	Kushal Shah
Address	:	Ghatkopar
Complainee	:	Oriental Insurance company
Address	:	8, VISHVA VINAY BUILDING, BEHIND JOHNSON & JHONSON,,BHAGOJI KIR MARG, MAHIM,,MUMBAI 16

Complaint Details
We have Mediclaim policy with Oriental Insurance company Limited.
Start date of policy : 29-03-2013 renewal every year

Mr.M B Shah was admitted during 14-Feb to 19-Feb at Nagher samaj hospital.

After discharged,I have submitted all the original documents for the
reimbursement claim to Medi-Assist TPA (Andheri-Mumbai Branch) - (TPA
of oriental Insurance co).

CCN CLAIM No - 10887100

As per Medi-Assist, they told we are not able to processed
the claim and rejected the claim and told me to directly contact
Oriental Insurance further.


so I have contacted Oriental Insurance for the same, Initially for
almost 1.5 months there were no reply and later after chasing
continusously
they told we are also rejecting the claim on the basis same as
Mediassist TPA have provided to you (Mentioned as below).

Rejection Reason -
Treatment happend for disease "Malabsorption syndrome" and cause of
this is Diabetes and Hypertension (Blood pressure)
and as per policy document existing disease (Diabetes (DM) and
Hypertension (HTN) ) not covered for 3 years from starting date of the
policy for existing disease.
and hence we are rejecting the claim.

I have submitted Original doctor's letter which clearly states that
primary treatment was "Malabsorption syndrome" and there
is no relation with DM and HTN. Also doctor's letter states
"Malabsorption syndrome" is Gastrointestinal Disorders and it is not
related to DM and HTN
but claim should not be denied by saying main cause of "Malabsorption
syndrome" is DM and HTN.


Also I mailed them hospital letter which also clears the same things.

Inspite of providing original doctors letter they have rejected the claim.

I have complaint against the decision taken for the claim.

I have concern how entire claim is rejected if some DM/HTN test/medicines
have been performed during hospitalisation which does not proves that
entire hospitalisation for DM and HTN and and cause is DM and HTN.

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