Name of Complainant	Xavier William
Date of Complaint	May 17, 2018
Name(s) of companies complained against	The Oriental Insurance Company
Category of complaint	Insurance
Permanent link of complaint	Right click to copy link
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Text of Complaint by Xavier William:

PETITIONER   : Xavier William, V/333B- Abraham Tharakan Road, Kochuvelikkavala, Ermalloor, Alappuzha 688 537. Mob: 9388605944 e-mail: eitctour@gmail.com

 

RESPONDENTS: 1. The Oriental Insurance Company, CBO-17 Herbal, C5017, No:12-Bellary

Road, Herbal, Next to Canara Bank, Bangalore, Karnataka 560024. Contacts: Deepa 080 23544118/ Deepika 23434131       email: deepa.panth@orientalinsurance.co.in as given on their website

 

2. Medi-Assist India TPA Pvt Ltd (MBuddy), Chicago Plaza, 4th Floor, Rajajaji

   Road,  Ernakulam 682 035 Tel: 0484-2384022/23

 

3. The Oriental Bank of Commerce, Broadway, Ernakulam 0484-2353777.

   Contact: Ajitha bml055@obc.co.in

 

4.. United India Insurance Co, Handicraft Building, Indira Gandhi Road,

    W.Island Kochi 682 003. Tel:0484-2667080

 

5. Perpetual Succour Hospital, Maradu, Ernakulam 683 304. Tel:

  04842705383

 

                       

FACTS OF THE PETITION

 

1. I am  70-years of age, retired and living at the address above.
2. I have a mediclaim insurance No:421504/48/2018/543 for the term 12/May/2017 to 11 May 2018 with the 1st Respondent. This policy covers me and my wife Sheela William, now aged 60. (My MA ID:5023353838, my wife’s MA ID:5023353839)
3. The above policy was a continuation of the mediclaim policy No: 421504/48/2017/340 for the year 2016 to 2017 with the 1st Respondent
4. Both the above policies were taken though the 3rd Respondent – The Oriental Bank of Commerce with whom I hold an SB account.
5. Before that we were covered by Mediclaim policies from 1997 to May 2016 by United India Insurance Company, the 4th Rspondent herein by Policy no:100202/48/97/00000456, the 4th Respondent herein.   
6. From the above it is clear that we have had continuous mediclaim coverage for 21 years from 1997 to the present.
7. We opted for the policy by the first respondent only because they offered a coverage of 5 lakh rupees for an annual premium of Rs.6990/- as against a coverage of only one lakh by the 4th Respondent -United India Insurance – for an annual premium of Rs.7231/-
8. Thus over the last 21 years we have paid a total premium of approximately Rs. 1,50,000/- whereas our total claims have been less than Rs.40000/-
9. We have not concealed any previous history of disease conditions either from the past insurer (The 4th Respondent) or the present one (The 1st Respondent).
10. Towards the end of Mar 2018, my wife experienced severe chest pain and other difficulties. We waited for a few days in the hope than the pain would subside. But it only got worse. So we approached the 5th Respondent hospital on Apr 2, 2018 and consulted their cardiologist since we suspected or feared that the chest pain may have had to do with some cardiac problems.
11. The Cardiologist admitted my wife as an inpatient for further observation and treatment.
12. On admission we were advised to approach the insurance desk at the 5th Respondent’s premises. This insurance desk contacted the 2nd Respondent who is the claim-processing consultant for the 1st Respondent, and submitted online all our papers on our behalf.  I received receipts from the 2nd Respondent for these papers by text messages on my mobile.
13. After due observations and treatments my wife was discharged at our request  on the 3rd of April – the very next day after admission – though the cardiologist advised that we stay on for 15 days for treatments.
14. At the time of discharge we paid the 5th Respondent a sum of Rs.14588/- towards the admission and treatments and our claim was forwarded by the 5th Respondent hospital to the 2nd Respondent.
15. On the 5th of April 2018, we received a text message from the 2nd Respondent, the 1st Respondent’s consultant stating (quote) “We express our inability to extend Cashless facility for claim 16713583. Use link https://mbudy.in/xk40hn7 to track your claim and reasons for denial. Download the MediBuddy app https://mbudy.in/emdtf7t to know more about your policy. Please do proceed with hospitalization as advised by your medical team.” (unquote)
16. I went to the online link as advised above to find that it too did not have any additional information than the above text message, which assigns no reason whatsoever for the inability to extend the cashless facility.
17. Ever since we have approached the 1st, 2nd and 3rd Respondents repeatedly for a clarification of the above cited text message from the 2nd Respondent. But no response has been forthcoming from any of the three respondents.
18. From the phone conversations with the 1st and 2nd Respondents, we suspect that the refusal of insurance payment is on the following grounds:-

1. Insurance coverage can be had only after 3 years of coverage whereas we have been insured with the 1st Respondent only for two years.
2. My wife had previous history of illness for which the insurance claim is made.
3. We had concealed this illness at the time of taking out the present insurance.

 

GROUNDS

 

1. The 1st and 2nd Respondents are bound to give reasons for their inability to extend cashless facility as quoted in clause 15 of the above section which they have not done in spite of repeated requests.
2. The verbal claim from the 1st and 2nd Respondents is that the refusal to extend insurance coverage is because our policy is only 2 years. The 1st and 4th Respondents are merely two arms of the same body – the state – and their primary purpose of existence is to serve the public/taxpayer and not the profit motive aloan. As stated above we have had continuous coverage since 1997 with the 4th Respondent before we received coverage with the 1st Respondent both of whom are merely two arms of the state. So the question of discontinuity does not arise when the policy was switched to the 1st Respondent from the 4th.
3. At the time of insuring with the 1st Respondent in 2016, the 3rd Respondent bank assured us that we would receive coverage since we had continuous coverage since 1997. What is more, Insurers insist on a thorough medical check-up and report when anyone takes out a new mediclaim policy especially for senior citizens. But in our case, the 1st Respondent did not ask for any such report of medical fitness in recognition of the fact that we had been insured for 20 years continuously. Consequently refusing our claim on the grounds of alleged previous history is untenable.
4. Our present  insurance policy does not state anywhere that we will not be covered for three years.
5. The verbal argument that my wife had a previous history is utterly false. In the case under consideration, she was admitted for chest pain and other symptoms associated with cardiac problems and the diagnosis is that she has no such problems. So the ‘previous-history’ argument does not hold any water. What is more there are several court judgments which say that previous history of disease is not adequate reason for refusal to settle claims.
6. If we wanted to take advantage of the 1st Respondent we could have gone to a very expensive hospital instead of going to the 5th Respondent hospital which caters mostly to the lower middle class.
7. The doctor had advised that we stay on for another fortnight for further treatments. If we had followed the doctor’s advice the 1st Respondent would have had to cover a higher claim than the present claim. From this it is obvious that we had no intention whatsoever of exploiting the insurer unfairly.
8. As stated above we have paid more than Rs.150,000/- to the 1st and 4th Respondents as premiums since 1997 whereas our claims have been only a third or less of this amount. We could have exploited our insurers for higher amounts as some hypochondriacs do.
9. It is more than 30 days since the cause of this petition arose and so there are no limitations for filing this complaint.
10. The Petitioner as well as the 2nd, 3rd and other Respondents as well as the cause of this Petition have risen in Ernakulam district, within the jurisdiction of this forum.

 

MEMO OF ESTIMATE OF DAMAGES

 

The total damages claimed herein consists of the medical expenses covered and the legal expenses for filing this petition and the total is as follows:-

 

1. Medical expenses charged by the 5th Respondent hospital    = Rs.14588.00
2. Legal expenses for filing this petition                                   = Rs.  5000.00

                                                                  Total Claim                    = Rs. 19588.00

 

(Rupees Nineteen Thousand Five Hundred Eighty Eight Only)

 

In light of the above facts and deposition it is humbly prayed that the Honourable Forum grant this Petitioner the following

RELIEFS

19588.   Allow the Petitioner to realize the Rs. 19588.00 (Rupees Nineteen Thousand Five Hundred Eighty Eight Only) as detailed in the Memo of Damages above from the Opposite Parties and their assets
19589.   Allow the Petitioner to realize an interest of 18% Per Annum on the above claim of Rs.19588.00 from the date of this petition to the date of its realization.
19590.   Allow such other reliefs which are deemed fit and proper.

The facts stated above are true.

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