Page 42 - Insurance Times August 2018

that the TPA had raised certain queries vide their letters
dated 25.07.2016 and 02.08.2016 which were replied by the
insured vide his letter dated 26.08.2016.
However, the insured informed vide letter dated
07.10.2016 that on receipt of complaint through this forum,
the claim was reviewed and the insurer had agreed to
settle the claim for Rs. 22,358/- subject to submission of
consent of the complainant. Subsequently, the complainant,
vide another mail dated 07.10.2017 has confirmed receipt
of claim amount. The complaint, thus, stands closed and
disposed off.
Syed Ahmed Ali Shah
V/S
Oriental Insurance Co. Ltd.
The complainant had taken Mediclaim Policy for the period
from 27.11.2015 to 26.11.2016 from The Oriental Insurance
Co. Ltd. He was hospitalized in Max Super Speciality Hospi-
tal, Ghaziabad on 26.08.2016 with acute ischemic stroke
and discharged from the hospital on 29.08.2016. The com-
plainant had applied for cashless facility but the same was
rejected by the company.
Thereafter, the claim was lodged by the complainant with
all the relevant documents for re-imbursement but the
same was too not settled by the company inspite of vari-
ous reminders. The company stated that the claim was
settled by them on 25.09.2017 after deducting the amount
of Rs.20,595/- due to non-availability of MRI films and ECHO submitted, the insurer is advised to ensure prompt settle-
reports. The insurer informed that they had confirmed from
the hospital that MRI was done and accordingly they were
settling the claim. That an amount of Rs.20,595/- was ap-
proved by the company for settlement of the claim was
later also confirmed by the complainant vide his e-mail
dated 08.11.2017.
Mr. Rajeev Kumar
V/S
United India Insurance Co. Ltd.
Mr. Rajeev Kumar, the complainant has stated that two
claims for treatment of his wife had not been settled by
the insurance company till date. Aggrieved, he had re-
quested the TPA/insurer including its GRO to reconsider the
claims but failed to get any relief. The complainant stated
42 The Insurance Times, August 2018
that he had submitted two claims amounting to Rs. 299179
for treatment of his wife to the TPA on 17.01.2017 but in
spite of various letters and telephonic calls, his claims had
not been settled by the insurance company till date.
The complainant informed that after lodging the complaint
in this forum, he had received payment of one of the claims
but another claim had not been settled by the TPA/insurer
till date. The representative of the insurer stated that in
spite of his best efforts, status of the pending claims could
not be obtained from the policy issuing office. He requested
for some time so as to enable him to get details of the
claims lodged by the insured. Accordingly, another personal
hearing was held on 17.11.2017. The insurer informed that
out of the two claims lodged by the complainant, one claim
for Rs. 93881/- had been paid and the complainant had
been advised to resubmit claim papers of the second claim
as the same could not be traced by the TPA/Policy issuing
office at Bangalore.
The complainant stated that he had already sent the claim
papers of the second claim to the TPA; however, he agreed
to resubmit the same. The insurer informed vide their mail
dated 29.11.2017 that the complainant has resubmitted
claim documents of the second claim for Rs. 1.73 lakhs to
the TPA and the admissible amount of the claim would be
settled shortly. It is observed that although, the complain-
ant had alleged inordinate delay in settlement of the
claims, he himself was confused and could not provide spe-
cific details of the claims. It appears that the complainant
had also not followed up the claims properly with the in-
surer. However, now that the documents have been re-
ment of pending claim.
Mr. Barun Kumar Chandra
V/S
Oriental Insurance Company Limited.
The complainant had taken Oriental bank Mediclaim Policy
for the period from 06/09/2016 to 05/09/2017 with sum in-
sured of Rs 200000/ for himself and his family. The spouse
of the complainant had problem of acute cholecystitis and
Cholelithiasis, where laparoscopic cholecystomy was con-
ducted on 28.02.2017. The complainant had lodged a claim
with the company for re-imbursement but the same was
rejected by the company . The complainant stated that the
company had rejected the claim of his spouse because of