KUSUM SHAH
9830375155
29-11-10
Dear sir,
i am an old aged patient suffering from broken waist, i was taken a health policy from national insurance co.ltd, division office 18, kolkata, i was lodged a claim for the same disease to the said company but till date my claim has not yet ben settled properly. i have mailed to the said insurance company and the tpa including all the required persons too. But no response have received from their end now i request you to kindly look into the matter the correspondence details are given below for your ready reference.
with warm regards
kusum shah
Wed, 3 November 1:17:33 PM Re: non proper settlement of claim under policy No. 101600/48/09/8500008679
From: Kusum Shah View Contact
To: [email protected]
Cc: [email protected]; [email protected]; [email protected]; [email protected]; Abhijit. [email protected]
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From:
KUSUM SHAH
P-70, BANGUR AVENUE,
KOLKATA - 700 055.
(M) 9830375155
To,
The Divisional Manager,
National Insurance Co Ltd,
Kolkata.
Date: 03/11
Dear sir,
Re: Policy No.101600/48/09/8500008679
IRDA GREIVANCE NO. 453/NIC/COMP/10-11
I am in receipt of the mail from TPA Office i.e.M/S Genins India Ltd.(Copy enclosed)
I am astonished rather socked to learn that they are stick to their decision and the document they are soughting is not practically possible for the patient like me. Moreover from their such act / behaviour it appears to me that some how or others they are biased and to prejudice my genuine claim. Once it is denied by them and now it seems to be the egoistic one to re allow the deducted amount. Henceforth such queries are being raised, so that the insured can't reply, since it happens beyond the range of the insured.
Any how, n response to the query, please be noted that I have already submitted them the receiving copy of the Centre through which Nurses were hired. It is not possible rather the duty of the patient / insured to keep her entire details. Those were hired by me through the Centre, where they can enquire directly for which I have no objection. Moreover, as per the policy condition, Nurses charges are payable, whenever she is qualified one. It is non where mentioned that in addition to her qualification, she should remain available to the insured at all the times. In case they desire, entire details of centre, i.e. telephone number and address is very much therein the submitted bill itself. In case of any assistance at my end i.e. any authority letter or my personal visit to the centre with TPA officials, please feel free to call me.
Needless to mention that the insured and insurer both are abided with the policy condition and as per the terms of the policy I am very much eligible for my genuine claim amount which you have deducted illegally by way of breaching the policy conditions.
Being the insurer I hereby request you to take up the matter and arrange to get settle my claim for which I am paying full premium regularly and in advance.
further, Non receipt of the claim will compell me to take up the matter to OMBUDSMAN which please note.
Thanking you
Trully your's
Kusum Shah
&-- Forwarded Message &-
From: Kusum Shah
To: IRDA Complaints
Sent: Sun, 31 October 10:05:16 AM
Subject: Re: non receved of mediclaim claim & wrong deduction
* Mandatory Fields
*Name of Complainant
Mr./Ms. KUSUM SHAH
Communication Details
Door No./ Bldg/Name/ Floor
P-70, 1ST FLOOR
Street / Area
BLOCK-A BANGUR AVENUE
*City/Town/Panchayath/Village
KOLKATA
Taluk/Tehzil
District
*State
WEST BENGAL
*Pin Code
700055
* E- Mail
[email protected]
Telephone No
*Mobile No
919836342101
Fax No
*Insurance Type (Please mentioned Insurance Type
*Life
* Non Life
NON LIFE
*Insurance Company Name
NATIONAL INSURANCE COMPANY LIMITED
Policy No:
101600/48/09/8500008679
Cover Note:
Other Reference No:
Details of the Complaint (Please type the full details of the complaint)
I was taken a mediclaim policy last year from National Insurance Co. Ltd Division Office XVIII Kolkata, and due to a bad luck of mine i fall down in floor by which i got badly injured, i have to admitted in hospital for an major operation, which takes a coast for Rs= 1, 15, 404/-, sir I didn't avail cashless service i invested all amount from my pocket, as because if we avail cashless services then the cost of treatment goes to higher side for this i didn't avail the cashless service, as per the company's mediclaim policy guideline they provide the coast @ 30 days before and 60 days after the treatment including HOSPITAL CHARGES, DOCTOR FEES, NURSING CHARGES, MEDICINE CHARGES, MEDICAL REPORTS, SERVICE CHARGES AND THE LIKE. Sir, i had gone through the company's guidelines, as per the norms of the policy i had submitted my claim to the TPA appointed by the said company.
Sir, i had submitted my claim on 22/JUL for the above said amount to the TPA named Genins India Ltd Kolkata, i received a letter
dated 28/07/10 from TPA as a query, i have submitted the reply of the said queries to the TPA office on 11/08. when i visited to the said TPA site to know the position of my claim, i became shocked that they had deducted around 45, 000/- from my claim, when i asked the said TPA that why did they did so, they replied as per our policy condition you are not eligible for receiving the said amount for nursing charges, but i had gone through the policy condition i am eligible to get the same, sir, the insurance co. has various types of health policies and having various types of clauses, but the policy which i had taken is having a eligiblity to give the deducted amount. I have many times mailed and given a hard copy with stamp, to the concerned persons but their is no response till date, Sir, i humbly request you to kindly look into the matter and ask them to settle my claim at early date..
*Have you Approached Insurance Company Regarding This Grievance (If Yes Provide Ref No)
YES
Regards,
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From: IRDA Complaints
To: Kusum Shah
Sent: Sat, 30 October 12:48:23 PM
Subject: RE: non receved of mediclaim claim & wrong deduction
Dear Sir/ Madam,
We acknowledge your mail.
As we found information to be incomplete to register your complaint, we request you to send the complete details in the below mentioned format or you can contact 155255 (Toll Free) to register the complaint.
* Mandatory Fields
*Name of Complainant
Mr./Ms. KUSUM SHAH
Communication Details
Door No./ Bldg/Name/ Floor
P-70, 1ST FLOOR
Street / Area
BLOCK-A BANGUR AVENUE
*City/Town/Panchayath/Village
KOLKATA
Taluk/Tehzil
District
*State
WEST BENGAL
*Pin Code
700055
* E- Mail
[email protected]
Telephone No
*Mobile No
919836342101
Fax No
*Insurance Type (Please mentioned Insurance Type
*Life
* Non Life
NON LIFE
*Insurance Company Name
NATIONAL INSURANCE COMPANY LIMITED
Policy No:
101600/48/09/8500008679
Cover Note:
Other Reference No:
Details of the Complaint (Please type the full details of the complaint)
*Have you Approached Insurance Company Regarding This Grievance (If Yes Provide Ref No)
Regards,
Consumer Affairs Department
IRDA
Basheerbagh
Hyderabad
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From: Kusum Shah [mailto: [email protected]]
Sent: Monday, September 13 10:13 PM
To: [email protected]
Cc: [email protected]; [email protected]; Abhijit. [email protected]; [email protected]; [email protected]; [email protected]; [email protected]
Subject: Fw: non receved of mediclaim claim & wrong deduction
& On Mon, 13/9/10, Kusum Shah wrote:
From: Kusum Shah
Subject: Fw: RE: reply of the letter from pranab dasgupta non receved of mediclaim claim & wrong deduction
To: [email protected]
Cc: [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], abhijit. [email protected], [email protected], [email protected], [email protected]
Date: Monday, 13 September, 4:35 PM
& On Mon, 13/9/10, Kusum Shah wrote:
From: Kusum Shah
Subject: RE: reply of the letter from pranab dasgupta non receved of mediclaim claim & wrong deduction
To: [email protected]
Cc: [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], abhijit. [email protected], [email protected], [email protected]
Date: Monday, 13 September, 4:30 PM
From:
KUSUM SHAH
P-70, BANGUR AVENUE,
KOLKATA - 700 055.
(M) 9830375155
Date: 13/09
To,
Mr. Pranab Dasgupta,
Genins India Ltd,
Kolkata.
Dear sir,
Re: Deduction of Nursing Charges under Policy No.101600/48/09/8500008679
I am in receipt of your mail dated 04.09.2010.
From the said correspondence it appears that either you have not gone through the submitted bill properly of M/s. ORIE NURSES CENTRE, or otherwise you have decided not to pay the amount by any means. In this regard it is my humble request rather advise also to you that prior to deduct the claim amount; reason for deduction should be valid and within the preview of the Policy conditions only.
Anyhow, as you have stated and agreed also that the Nursing charges / expense is incurred by me is for my confinement at home. At the same time you also expect that the bill should be issued by Hospital / Nursing Home. Is it really possible? To best of my knowledge they can issue and charge the bill till the patient’s stay with them and not after discharge. Balance part of patient’s treatment has to be arranged of his own. In this case I have hired the service of an authorised and independent professional agency. Moreover the Nurse on duty was qualified one. Xerox copy of his qualification as a qualified nurse has already been submitted to you with the claim.
Henceforth, I am very much eligible for the claim amount under clause no. 1.8, i.e. as Post Hospitalization claim.
Hope the matter is clear at your end and will enable you to settle the deducted amount at an early date.
Needless to mention that non compliance of the matter will compel me to take up the matter to OMBUDSMAN, which please note.
Thanking you
Trully Your's
KUSUM SHAH
& On Sun, 5/9/10, [email protected] wrote:
From: [email protected]
Subject: RE: non receved of mediclaim claim & wrong deduction
To: [email protected], [email protected], [email protected], [email protected], [email protected]
Cc: [email protected], [email protected], [email protected], [email protected], abhijit. [email protected], [email protected], [email protected]
Date: Sunday, 5 September, 8:55 AM
Dear Sir,
Please find attachment.
Pranab Dasgupta
Manager - Grievance & Audit
Genins India TPA Ltd
19, R.N.Mukherjee Road,
kolkata - 700 001
e-mail: [email protected]
Mobile : 9674740967
&-- Original Message &--
From: [email protected] [mailto: [email protected]]
To: [email protected], [email protected], [email protected], [email protected], [email protected], [email protected]
Cc: [email protected], [email protected], [email protected], [email protected], abhijit. [email protected], [email protected], [email protected]
Sent: Sat, 4 Sep 2010 18:00:53 0530
Subject: RE: non receved of mediclaim claim & wrong deduction
Dear Sir,
The insured submitted claim documents on 22/07/10 under Sampoorna Arogya Policy. The claim No.was generated i.e. NI-6-57667 on receipt of the claim documents. Due to insufficiency of some documents we requested the Insured vide our letter dated 28/07/10 to comply with documetns. On 11/08 we received the documents & accordingly processed the claim as per the enclosed sheet. Certain deductions were made as stated in the enclosed sheet, according to policy conditions. We refute the allegation of the Insured of 'wrongly deduction in claim'.
Service charge is included within the Hospitalization benefit sec.1 & hence included in the room/ boarding expenses. With regards to Nursing charges, the same becomes payable only if provided by the Hospital/Nursing Home as per definition under clause 1.10.
While scrutinizing claim documents it is noted that insured has submitted a bill from 'Orie Nurses Centre' of Rs.43400/- against Nursing expenses incurred for the patient at home. It is to be noted that the said bill has been issued by Nurses Centre & is not by hospital/Nursing Home. Considering the policy clause, the above submitted bill from a Nursing centre is not sustainable & hence was deducted from the amount of claim.
Pranab Dasgupta
Manager - Grievance & Audit
Genins India TPA Ltd
19, R.N.Mukherjee Road,
kolkata - 700 001
e-mail: [email protected]
Mobile : 9674740967
&-- Original Message &--
From: Neelam [mailto: [email protected]]
To: [email protected], [email protected], [email protected], [email protected]
Cc: [email protected]
Sent: Sat, 4 Sep 2010 11:45:38 0530
Subject: Fw: non receved of mediclaim claim & wrong deduction
Please look into the matter and do needful at the earliest.
Thanks & Regards,
Genins Team
&&-Original Message&&-
From: Kusum Shah
Date: 9/4 4:40:50 AM
To: [email protected]
Cc: [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; abhijit. [email protected]; [email protected]
Subject: non receved of mediclaim claim & wrong deduction
From:
KUSUM SHAH
P-70, BANGUR AVENUE,
KOLKATA - 700 055.
(M) 9830375155
04/09
To,
The Finance Minister,
Sri, Pranab Mukherjee,
Sansad Delhi.
Dear sir,
I was taken a mediclaim policy last year from National Insurance Co. Ltd Division Office XVIII Kolkata, and due to a bad luck of mine i fall down in floor by which i got badly injured, i have to admitted in hospital for an major operation, which takes a coast for Rs= 1, 15, 404/-, sir I didn't avail cashless service i invested all amount from my pocket, as because if we avail cashless services then the cost of treatment goes to higher side for this i didn't avail the cashless service, as per the company's mediclaim policy guideline they provide the coast @ 30 days before and 60 days after the treatment including HOSPITAL CHARGES, DOCTOR FEES, NURSING CHARGES, MEDICINE CHARGES, MEDICAL REPORTS, SERVICE CHARGES AND THE LIKE. Sir, i had gone through the company's guidelines, as per the norms of the policy i had submitted my claim to the TPA appointed by the said company.
Sir, i had submitted my claim on 22/JUL for the above said amount to the TPA named Genins India Ltd Kolkata, i received a letter
dated 28/07/10 from TPA as a query, i have submitted the reply of the said queries to the TPA office on 11/08. when i visited to the said TPA site to know the position of my claim, i became shocked that they had deducted around 45, 000/- from my claim, when i asked the said TPA that why did they did so, they replied as per our policy condition you are not eligible for receiving the said amount for nursing charges, but i had gone through the policy condition i am eligible to get the same, sir, the insurance co. has various types of health policies and having various types of clauses, but the policy which i had taken is having a eligiblity to give the deducted amount. I have many times mailed and given a hard copy with stamp, to the concerned persons but their is no response till date, Sir, i humbly request you to kindly look into the matter and ask them to settle my claim at early date.
Thanking You
Trully Your's
Kusum Shah
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