Mediclaim Rejected Due To Unjustified Reason. Grahak Suraksha

My Name: Gondaliya Rajesh Jagdishbhai
My Complaint Against: National Insurance Co.Ltd. Kalol and TPA: Heritage Health Services Pvt.Ltd Ahmedabad
Contact of Complaint Against:
National Insurance Co Ltd
Kallol Branch
Shakti Shopping Center, 2nd Floor, Veparijin Compound, Behind ST
Pincode : 382721
Telephone : 259184/223191
Fax : 259184
Email : [email protected]

Complaint Category:
Insurance Companies
My Complaint Description:
I have mediclaim of National Insurance company Ltd (TPA: Heritage Health Services Pvt.Ltd) for my father and mother. Please find details of insurance and claim as below

Policy No: 301103/48/10/8500003058
Agent code: 91146000000001
Development officer code: 911460
Card No: HHS1.0333268702
DOA: 07/05/2011
Dt of Intimation: 05/07/2011
Claim No: Claim No HH131202546 and HH131203449 (Gondaliya Jagdishbhai)

My father (Gondaliya Jagdishbhai) was operated two times for Rt Empyema with esophageal fistula by Dr. D G Yagnik ( Yagnik Nursing Home , Ahmedabad ) and for that I had submitted all the required documents to Herritage Health TPA in July 2011 and August 2011 subsequently .

After so many follow up and complain to IRDA (IRDA Token Number : 12-11-031095 ) On 20th January I got rejection letter from National Insurance Comp Ltd, stating that Pre existing disease not covered in the policy

This disease was not preexisting as we came to know after CT scan on 29/06/2011 and Chest P A decubitus and Barium Swallow test on 04/07/11, during investigation

None of TPA executive or medical expert had contacted my Dr. D G Yagnik for the details of the Disease. As per the certificate and details provided by by Dr D G Yagnik in claim form it is clear that “Right Empyema with esophageal fistula” is not a preexisting disease. As mentioned by Dr D G Yagnik in 1st claim form as well as 2nd claim form that this disease was identified during investigation for chest pain and fever (apx 1 month)

Again I had escalated the complain on IRDA site on 9th feb as per suggestion from IRDA with details (document attached). Just after that I got again same rejection letter zerox copy via courier from National Insurance Company Ltd, Kalol. By Mr. D K Ambalia.

After that I had given application to National Insurance Kallol branch to reopen the file with supporting doccuments (additional certificate from Dr Yagnik ) stating that the disease is not preexisting.

After so many follow up and mail to IRDA and Heritage Health insurance , no body is responding..

kindly help me to get my father’s claim .

Rajesh Gondaliya

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