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Oriental Insurance Company Ltd - Non Settlement of Medical Insurance claim even after submitting all necessary documents to the Compa

Nitin Bhandari filed complaint against Oriental Insurance Company Ltd on Mar 3, 2024

I am having Medical Insurance Policy of Oriental Insurance Company from last **+ years which covers the claim of me and my family. My daughter Miss Pooja Bhandari is a special child and she suffered with an accidental trauma on **th November ****. causing dentoalveolar damage. The patient has severe epileptic episodes and had fallen at home due to which the accident occurred. On clinical examination, fractures were seen with upper anterior teeth and loss of crown structure with posterior teeth which needed urgent attention, Since, the patient is a known case of mental retardation, the patient had to be operated under general anesthesia for a full mouth rehabilitation, The procedure included Splinting of the fractured upper anterior teeth and multiple root canal
treatments followed by tooth capping, extractions and tooth-coloured fillings. The procedure was completed in * hours without any complications. The patient was monitored closely postoperatively for * hours in day care and was put on medications for * days.
On approaching the Insurance Company PARAMOUNT HEALTH SERVICES which is a part of Oriental Insurance Company for claim settlement, it raised several queries relating to the details of the incident (how, when and when did it occur), Also the Company required clarification regarding charges of hospital (OT notes, anesthesist, final bill charges, etc.
and Xray reports of the treatment.
In response to your query raised by the Company,
We had submitted all the reports and necessary documents. In discussion with company for further update on claim, it wanted clarification from hospital regarding the incident which we have further provided to the company with the Xray reports. Besides this, the Company is demanding the reasons for the charges levied by the hospital for the treatment done. We stated that the the consultation with reports and bill charges of operation, anesthetist, surgeon, ot charges and final bill charges are levied by the hospital. The Company need to contact the doctor and hospital department for the clarification of charges as it doesn't fit in our scope.
Further, on phone conversation with Mr. Sagar Pawar Customer Relationship Manager of PARAMOUNT HEALTH SERVICES AND INSURANCE TPA PVT. LTD, he talked very rudely saying the claim will be rejected as the patient Miss Pooja Bhandari has undergone a treatment that is not mentioned in claim documents and it is misrepresented and discrepancies are there.
Even after providing all the necessary documents to the Company, they are harassing us for not approving the claim and not cooperating with the patient's health taking into consideration she is a special child.
Also, if such cases are being rejected due to irrelevant requirements of documents and even after clearing all discrepancy, we wont be able to trust on such companies even after paying premiums and who assure to process the claim settlement in a hassle free manner.

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Complaint Status

Resolution Demanded:

Apology letter from company

Damages for loss and agony

Oriental Insurance Company Ltd

4

Total Complaints

1

Total Resolved

25.00%

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