COMPLAINT AGAINST: NEW INDIA ASSURANCE COMPANY Ltd., D O, 120700, MUMBAI.

Dated 20th January 2025 

The E.D, [E&OS]

LIC OF INDIA,

CENTRAL OFFICE,

"YOGEKSHMA"

MUMBAI.

Respected Sir,

Re: Complaint against non-settlement of Claim correctly – Claim No: 119614975 & 124109112 under Policy No. 12070034230400000004 & 12070034240400000004 Group Policy issued by New India Assurance Company Ltd., DO 120700 Mumbai.

Raksha TPA.

COMPLAINANT: Dr. R K MITTAL

AGAINST: NEW INDIA ASSURANCE COMPANY Ltd., D O, 120700, MUMBAI.

POLICY Nos : 12070034230400000004 & 12070034240400000004

TPA:  RAKSHA TPA Pvt. Ltd.,

BRIEF HISTORY OF THE CASE:

I am a retired Divisional Manager of LIC of India. LIC of India started taking Group Medi Claim Policy from Non-Life Insurers from 01-01-1988 for the benefit of their Employees and Retired Employees. I have been covered under this Group MediClaim Policy since the beginning. My present Sum Insured is Rs. 40 LAKHS.

Most unfortunately, I  was diagnosed with the Carcinoma of the Bladder, High Grade with CIS, TIG 3 in June 2015. I would like to clarify that at the time the Carcinoma was detected I WAS NEITHER DIABETIC NOR HYPERTENSIVE.

As per the Group Policy Conditions under: A. Coverages, Sl No. 7 (appearing on Page 4 of 2024-25 policy document) “In case of Renal Failure and/or Organ Transplantation and/or Cancer-related ailments/Treatments limit of 60 days for Post-Hospitalisation is not applicable.......”. Since the diagnosis of Bladder Cancer, the treatments continued till date and will continue till my lifetime. BCG Induction and Cystoscopy were done in 2016, 2017, 2018, 2019, 2022 & in Feb 2023. THE REIMBURSEMENT WAS MADE BY THE TPA/NIA WITHOUT ANY QUERY except once when the TPA disallowed cost of some Medicines, on representation to the SDM, NIA DO 120700 not only he allowed the payment but ALSO COMMENTED THAT ALL MEDICINES PRESCRIBED IN DISCHARGE SUMMARY ARE PAYABLE (OVER PHONE WHEN I HAD CALLED HIM).

Because of Cancer, I developed Hypertension in 2019 and became Diabetic in 2022. I was told by my Oncologist that BP & Sugar are normal effects of Cancer Treatment. THESE DISORDERS ARE DIRECTLY ATTRIBUTABLE TO CARCINOMA. So my Oncologist referred me to a Physician and advised me to take the Medicines prescribed by the Physician along with the Medicines prescribed by him, regularly to keep Cancer under control.

I used to purchase 6 months of Medicines at a time to avoid visiting the Pharmacy every month also the above referred clause (A.7) under the Policy prescribed minimum reimbursement should not be less than Rs.10,000/- (now reduced to Rs.5,000/-).  I am thankful to the Raksha TPA working on behalf of NIA and New India Assurance company for settling the Claim for the Medicines purchased as per the prescription of the Oncologist and the Physician till 2023, without any query, except for the one incident quoted above.

I WOULD ALSO LIKE TO BRING TO YOUR KIND NOTICE THAT THE CANCER TREATMENTS LIKE CHEMOTHERAPY, RADIOTHERAPY, etc., ARE TREATED AS HOSPITALISATION TREATMENTS as per section G. DEFINITIONS:  Sl No. 10 on page 25 of the Policy Document for the year 2024-25 (similar provisions were there in earlier policy documents also) on Domiciliary Treatments. Hence, the Treatments taken for Carcinoma are to be treated as Hospitalisation Treatments only. Therefore the non-settlements listed under this clause are NOT APPLICABLE TO Hospitalisation treatments. WHICH SIMPLY MEANS THAT ALL THE MEDICINES PRESCRIBED BY ONCOLOGISTS AND PHYSICIANS ARE ELIGIBLE FOR REIMBURSEMENT.

The TPA & Insurer (NIA) have correctly settled all the Medicine Bills from 2019 to 2023, every half year, without any objection or query, except for the one incident quoted above.

However, the dawn of 2024 has changed the attitude of the TPA and also the New India Assurance Company Ltd.,

COMPLAINT :

1) My Feb 2024 Claim for the Medicine of 6 months was purchased as prescribed on 23/02/2023 by the Oncologist and Physician till the next date of Cystoscopy in 2025.

I purchased, as usual, 6 months of all Medicines prescribed on Discharge and submitted a Claim for Reimbursement on 16-02-2024. The Claim No allotted is 119614975 for Rs.44,730/-.

The TPA while settling the above Claim disallowed Rs.14,670/- being the Medicines for BP & Diabetics.

I appealed to the GRO who also turned down my Claim to pay the wrongly deducted amount.

I filed an appeal to the Ombudsman, who vide their Award dtd.10/05/2024 directed the Insurer to re-review the case and pay to the complainant, if any.

The Insurer vide his letter addressed to me, dtd. 27/05/2024 informed that they have re-reviewed the case and NOTHING IS PAYABLE as the cost of Medicines for BP and Diabetic are NOT RELATED TO CANCER.

2) I purchased all the Medicines prescribed as per the Discharge Summary prescription dtd. 23/02/2023. Submitted the Bill for Reimbursement on 20-08-2024 to the Raksha TPA for Rs.36,990/-. Claim No allotted is 124109112.

The TPA, like in Feb 2024 claim settlement, deducted Rs.23,808/- settled only Rs.13,182/- only. Out of EIGHT medicines prescribed, the cost of only TWO medicines were reimbursed.

I wrote to the Primary GRO i.e. Divisional Manager, New India Ass Co Ltd., to pay the balance amount of Rs.23,808/- which was turned down.The medicines, ZURIG 40,SUPERCAL & MAGANOURM  OD PLUS have also disallowed saying that these are the medicines for HTN & DM.

3) It is the experience of all Cancer patients in India, that the New India Assurance Company through their TPAs are harassing the Cancer Patients by disallowing many items in the Bill on one or the other reasons. In a few cases, the NIA DO 120700 has settled some amount out of the deducted amount (this is the experience of Sri K T Hemanna, a Cancer patient, who breathed his last about 2 months back). But in my case, because I had complained against them and approached the Ombudsman, I feel they are NOT ready to consider any of my appeals to them.

PRAYER :

I pray the following to your goodself:-

Order the New India Assurance Co., Ltd., Divisional Office, 120700, Mumbai to settle the wrongly deducted amount under my above 2 Claims viz Rs.14,670/- + Rs.23,808/- = Rs.38,478/- for the Medicines prescribed as per Discharge Summary dtd.23-02-2023.

To order the Insurer to Reimburse the Cost of all Medicines, prescribed by the Oncologist and Physician in the future also.

To award exemplary damages for the mental agony undergone by me due to the wrongful deductions while settling the Bills to a Super Senior Citizen, who is counting his days.

To admonish the NIA to treat the Cancer patients with dignity and NOT to harass them.

Thanking you,

Yours faithfully,

 (Dr. R. K. MITTAL)

        Copy forwarded to the following  for information  & necessary  action:-

1.ED [P], LIC, CENTRAL OFFICE, MUMBAI.

2.Managing Director, LIC, CENTRAL OFFICE MUMBAI. 

(Dr RK Mittal)