Repudiation of Covid 19 Domicilliary Hospitalisation Claim of Sri D V Aloni

NATIONAL ORGANISATION OF INSURANCE PENSIONERS 

Regn No.PN 4769 (Regd under Indian T U Act,1926) (Affiliated to Bharateeya Mazdoor Sangh) BMS Office, Vishwakarma Bhavan, 185, Shaniwar Peth, Pune 411030. Tel.: 020-24454040    

President: Dr. S. B. Sharan        Working President: S. G.Elangadi  General Secretary: Vilas V.Purkar  Mob No: 09868358161                  Mob No: 08762932477  

Mob No: 09922166599                             ------------------------------------------------------------------------------------------------------------------------------------------             Date : 24-04-2021 

To, 

The Chairman cum Managing Director, The New India Assurance Co., Ltd., No:87, M G Road, Fort, MUMBAI – 400 001.  Respected Sir,   

Re : Repudiation of Covid 19 Domicilliary Hospitalisation Claim of Sri D V Aloni and                Smt. S D Aloni under Group Health Insurance Policy No.12070034200400000001. 

 

This letter is addressed by me as General Secretary of National Organisation of Insurance Pensioners' – the Registered Trade Union  of Pensioners' of LIC of India. The aggreived Claimant is a Member of our Organisation. All his personal efforts to get the redressal of his grievance by the Divisional Office, 120700  and Regional Office III of your esteemed Company have failed and hence, as an Organisation we have stepped in to get the grievance of our Member redressed. As per Grievance Redressal Policy published by the New India Assurance Co., Ltd., you are the final authority to resolve the grievances, I am addressing this letter to you Sir, for your kind and favourable consideration.  The facts of the case are as under : Unfortunately, both Sri D V Aloni and his spouse, who are living at Pune got afflicated by the Pandemic Covid 19 on 30-09-2020. The situation in the Country and Pune was as serious at that time as it is today. The Hospital Beds were not available easily and patients were advised by their Doctors to get the treatments in Home Isolation. The family doctor- Dr. Khanna, MBBS, to whom they consulted advised them to take treatment in Home Isolation which they did for the period from 02-10-2020 to 14-10-2020. The Family Doctor's letter clearly states that since, Beds were not available they were advised to take 

treatment for the dreaded Covid 19 at Home. The Doctor used to monitor the Body Temperature and Oxygen Level twice every day on Phone and advise the line of treatments. The Group Medi Claim Policy taken  by LIC of India, Central Office,  Mumbai for the benefit of their present and past employees, with NIA Divisional Office, 120700 contains provision for Domicilliary Treatment reimbursement where Domicillliary Treatment is taken on the advise of a Medicalman on any of the following TWO conditions : •The condition of the patient is such that he/she is not in a condition to be removed to a Hospital. OR •The patient takes treatment at home on account of non-availability of room in a Hospital. The liability of the Company is restricted to 20% of the total Sum Insured per person. (Please refer Pages 23 & 24 of the Policy Document under the Head  G) DEFINITIONS.  Therefore the Claimant in this case is entitled to Reimbursement of the Amount spent by him of Rs.13,659-00 for Sri D V Aloni and Rs.12,871-00 for Smt Shilpa D Aloni. The condition (2) above is satisfied in this case. The reason given by the TPA and upheld by NIA DO, 120700 for  Repudiation is on trivial reason that the Doctor has not monitored on day to day basis. In a highly contageous Pendamic situation like Covid 19, no Doctor used to visit to check the Covid patients. So daily readings of Temperature and Oxygen Level were informed to him over Phone and he  used to advise the line of Treatment. IT IS IRRATIONAL, IMPOSSIBLE TO EXPECT  THE VISIT OF DOCTOR TO HIS HOUSE TO CHECK TEMPERATURE AND OXYGEN LEVEL. The Temperature and Oxygen Level chart for both patients, noted by the Claimant – as per Doctors advise and signed by him, is enclosed with this letter for your ready reference.  I here below give the details of both the CASES.   1.  MDI Claim control Number : MD15914638             IC control Number :TP00512070020900695413             Claim Status : Claim has been repudiated.             Claim amount : Rs.13,659/-             Name of the Patient & Claimant : D V Aloni.   2.  MDI Claim control Number : MD15914632                IC control Number :TP00512070020900695409               Claim Status : Claim has been repudiated. 

   Claim amount : Rs.12,871/-               Name of the Patient : Smt Shilpa Aloni               Name of the Claimant : D V Aloni   The flexi floater Sum Insured is Rs.50,00,000/-  I therefore request your goodself to go  through all the papers and take a rational, kind and favourable decision  keeping in view the circumstances prevailing at that time.  A favourable reply is highly appreciated.  Thanking you,  NASHIK                                                                                                           Yours faithfully,                                                                                                                                                                                                                                                  V V PURKAR                                                                                                                      ( General Secretary) 

Encl : 

•The daily chart of Body Temperature and Oxygen Level duly certified by Doctor. 

Doctor's letter dated 31-03-2021 clearly stating non-availability of Beds and  advising for Home Isolation and Treatment. 

•Letter dated 17-01-2021 addressed to Grievance Redressal Officer, RO III, NIA, Mumbai. 

•The above letter was sent to the TPA. All other Documents are available in your above referred Divisional Office.     

C c to : •RM, NIA, RO III, Mumbai •SDM, NIA DO, 120700, Mumbai •MD India HealthCare Services, TPA Pvt., Ltd., 

To all above 3 receipients to settle the Claim favourably and immediately. 

•Executive Director (Per), LIC of India, C O, Mumbai 

•Executive Director (E & OS), LIC of India, CO, Mumbai With a request to ED(P) and ED(EOS) to take up the matter with NIA and to settle the claim as per rules, as per Policy Document. 

•Sri R K Sahni, for favour of publication in Pensioners' Blog.