Consumer Protection Act
Rajeshwar Dayal
(Querist) 17 February 2016
This query is : Resolved
I'm a member of Group Medi claim policy taken by my employer from National Insurance Co.Ltd.The sum assured w.r.t me is Rs.2 lacs.(b) In July,2015 I was operated for Cataract surgery( left eye) at Centre for Eyesight, Roop Netralaya,Meerut,by Dr.Roop,M.D(Opthal)AIIMS Delhi.Regd.no.5095. This surgery was done by Femto procedure & while processing my claim Genins India TPA Ltd.has deducted Rs. 47,500 & stated that as per Insurance Co.instructions Femto procedure charges are not payable.I have lodged a complaint to Grievance cell,Divisional office, Dehradun,stating that in the Mediclaim policy issued to the employer there are no maximum limit of reimbursement/payment of treatment of eye surgery & it is not mentioned anywhere that the charges regarding the payment of the procedure of Femtosecond laser for the removal of the Cataract will not be allowed/not be claimable.Please advise.R.Dayal
Rajendra K Goyal
(Expert) 17 February 2016
If the claim was rejected beyond the terms of insurance, lodge complaint with the consumer forum.
Kumar Doab
(Expert) 17 February 2016
Look into the exclusion and Inclusion criteria carefully.
The master policy is with employer.
Submit to employer also and let employer also take up with Insurer.
If T&C of insurance policy are not complied with you have the option to lodge complaint with co. and that you have done.
If they are not replying escalate to MD, Chairman and even IRDA, Insurance Ombudsman or pull them to DCDRF.
