Struggling for Fairness: A Senior Citizen's Battle with National Insurance Company Limited

Introduction

In a distressing series of events, a senior citizen has found himself entangled in a web of bureaucratic inefficiency and negligence at the hands of National Insurance Co Ltd (NICL). This blog delves into the ordeal faced by Mr. Sharma, a long-time policyholder, as he battles against the illegal short settlement of his medical claim. This narrative underscores the frustration, distress, and sheer perseverance of an elderly individual seeking rightful justice.

The Onset of Trouble

Mr. Sharma, a senior citizen, holds the 'National Senior Citizen Mediclaim' Policy with NICL. His policy covers a sum insured of ₹3 lakhs, accompanied by a cumulative bonus of ₹77,000. In December 2023, due to severe lower back pain, he was hospitalized at "Stavya Spine Hospital & Research Institute Pvt Ltd." Following medical consultation, surgery was recommended, and he was admitted to the hospital on December 19, 2023. After a successful surgery, he was discharged on December 23, 2023.

Claim Submission and Initial Response

Diligently gathering all necessary documents, Mr. Sharma submitted his claim to the TPA MD India on January 6, 2024. The total claim amount was ₹5,04,120, exceeding his sum insured of ₹3,77,000. The claim was registered under claim number CCN XXXXXXXX and insurer claim ID XXXXXXXXXXXXXXX. However, on January 16, 2024, he received an email from the TPA, stating that only ₹94,250 had been settled. A staggering deduction of ₹4,09,870 was applied, resulting in a shortfall of ₹2,82,750.

Unjustified Deductions and Rejection

Bewildered by this deduction, Mr. Sharma promptly contacted the TPA, seeking reconsideration. The deductions were made in violation of applicable rules, and no prior notification was provided. Despite his efforts, the TPA failed to offer a satisfactory response. The situation escalated when the TPA requested a justification letter for an alleged "Robotic Surgery." The hospital promptly provided a letter dated January 18, 2024, clarifying that no robotic surgery was conducted, and the charges were for a regular surgery. Despite submitting this letter on January 19, 2024, the TPA rejected his request for reconsideration on January 24, 2024, citing a blanket deduction of 25% of the total Sum Insured as the final settlement.

Seeking Redressal and Insurer's Response

Undeterred, Mr. Sharma reached out to NICL. On February 1, 2024, he submitted an online complaint, providing the hospital's justification letter. However, on February 22, 2024, the Insurer rejected his request for reconsideration. While admitting there was no "medical indication" for robotic surgery, the Insurer declined to reconsider the claim, relying on presumptions instead.

Key Submissions and Violations

Mr. Sharma's submissions highlight several critical points. Firstly, the policy's terms and conditions, cited by both the TPA and the Insurer, were never furnished to him. Without these documents, the terms cannot be enforced against him. He requested a copy of the detailed policy terms and conditions, including the date of delivery.

Secondly, the Insurer's letter dated February 22, 2024, acknowledged that no robotic surgery was performed or charged for. Despite this, the claim was not reconsidered. The categorization of a regular surgery as robotic, based on assumptions of exaggerated charges without evidence, appears to contravene IRDAI guidelines and the Consumer Protection Act, 2019.

Additionally, a blanket deduction was applied to the entire hospitalization expenses, with only 25% of the Sum Insured disbursed. The referenced policy clause 1.2.11 (Modern treatment) applies only when "medically indicated," which was not the case here. The hospital explicitly stated that it was a regular surgery. This categorization under "modern treatment" without evidence raises concerns about malicious intent.

Call for Justice

Given these circumstances, Mr. Sharma has demanded a detailed investigation into his case and the immediate approval of the claim balance of ₹2,82,750, which was wrongfully denied, including the accrued interest. He also insists on receiving all the documents and information previously requested from the insurer.

Conclusion

Mr. Sharma's experience with NICL and its TPA highlights significant flaws in the insurance claim settlement process. The frustration and distress endured by a senior citizen in his quest for justice are palpable. This case underscores the urgent need for transparency, accountability, and adherence to regulations in the insurance industry. It serves as a poignant reminder of the struggles faced by elderly individuals in navigating complex bureaucratic systems to secure their rightful entitlements.

Disclaimer: This blog is based on the written complaint and evidence provided by the victim to the insurer. It is not intended to defame any individuals or organizations mentioned. The insurer works diligently to address grievances, and this blog aims to raise awareness about current insurance practices.