Sub: Claim no. HH121101099, Policy no. 250800/48/09/86500008832/ 250800 dated 8th Feb of National Insurance Co. Ltd. (NIA)
We have a family "BOI National Swasthya Bima Policy" of National Insurance Company (NIC) from 8-2 to 7-2. The patient, my wife, Renu Seth, was hospitalised at Agarwal Clinic, Mumbai from 7-4 to 9-4 with the diagnosis of Parotid abcess (Parotitis). Our Insurance claim for approx Rs. 18, 000/- was submitted to NIC s TPA Heritage Health, Mumbai on 5th May.
As per NIC s mail dated 13 Sept NIC s TPA has rejected our claim saying " Paratoid Abcess is direct complication of diabetes in view of low immunity because of diabetes which makes the patient more vulnerable to secondary infection and abcess formation. Hence, the case was repudiated on basis of pre-existing clause under policy as it is related to diabetes which is an exclusion under policy". I have not accepted the reasons of their rejection as I find it highly unconvincing, arbitrary, unjustified and unfair.
I have following complaints against NIC and its TPA Heritage Health which are not yet resloved to my satisfaction:
1)). Immediately on admission, the Hospital submitted the case papers to NIC s TPA Heritage Health who earlier approved for Cashless Settlement (vide Claim no. HH121100168) for this case, which unfortunately I could not take advantage of as I took earlier discharge of patient from the Hospital due to poor facilities and services. And now when I have submitted the claim for Re-imbursement, they have rejected it citing the reason of Pre-existing disease. This amounts to double standards by NIC and the TPA, first approving the case for cashless settlement and then now rejecting the re-imbursement claim.
2)). I had referred the case papers to my family doctor as well as my brother-in-law who is a Senior Surgeon (F.R.C.S., UK) in one of the topmost private Hospitals in Delhi (their team of Surgeons is amongst the panel of Doctors for the President of India). The senior Doctors/Surgeons alongwith my brother-in-law have opined that the primary reason for the abcsess is infection in salivary gland and it cannot be proved conclusively that the Parotid Abscess was caused by Diabetes and none of the medical research and documentation available points to this. Also none of the medical websites state that diabetes is the cause for Parotid abscess. NIC / Its TPA have failed to provide any documentary or medical proof that the abscess was caused by diabetes. NIC and its TPA are taking us for a ride. I want definite medical reasons / proof that Parotid abcess (or Parotitis) in my wife s case under the subject, was caused by Diabetes.
3 )) How can NIC reject my claim on the basis that "The hospitalization is also in close proximity to the inception of the policy as mentioned earlier" when 30 days limit is clearly defined in NIC s policy document. A company like NIC should stand by the wordings in the Policy Document. Given below is the extract from the Exclusion clause of NIC s own Policy document and it is also given on the official website of NIC. It clearly says 30 days limit from the date of commencement of Policy and not 60 days or two months.
"Exclusions - Any hospitalization expenses incurred in the first 30 days from the commencement date of Insurance cover except in case of Injury arising out of accident.")
4 )) NIC s mail tells that Parotid Abcess required incision and drainage. But the Parotid abcess was fully cured with post hospitalisation medication with antibiotics and did not require any incision and drainage. Once again it proved that the abscess was not caused by diabetes.
5 )) In addition, the services provided by NIC s TPA Heritage Health are extremely poor and third rate as they, even after repeated follow-up, did not respond nor gave any feedback or reply to me even after 4 months of submission of my claim and I was forced to approach the CMD of NIC to get a reply. Such a TPA is a shame to the Insurance fraternity and the Insurers and I strongly recommend that Heritage Health should be blacklisted for ever.
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