United India Insurance Company Limited - WrongFul Rejection of Mediclaim

They have wrongfully closed a legal option for us through the Insurance Ombudsman by proposing a reevaluation of our claim and subsequently rejecting it on non-existent technical grounds. Additionally, they have caused intentional delays in the evaluation of our insurance claim, the processing of the Ombudsman order, and the reevaluation process.
Details of the Incident:
Background:
I, Deepak Goel, residing at **/*** Heritage City, MG Road, Gurgaon, Haryana, ******, had filed an insurance claim with United India Insurance Company Limited for the treatment of ALK+ve cancer, which is a genetic form of cancer predominantly occurring in non-smokers. The treating doctor provided a certificate confirming ALK+ve cancer, and we submitted two test reports supporting this diagnosis.
Ombudsman Order:
The Insurance Ombudsman issued an order (Complaint Ref: DEL-H-***-****-****, Award No: IO/DEL/R/HI/****/****-****) stating that the insurance company should not consider smoking as a contributing factor to ALK+ve cancer, but rather acknowledge it as a genetic cancer. The insurance company agreed to reconsider the claim based on this order​​.
Proposal for Reevaluation:
The insurance company, through their TPA Vidal Health, proposed a reevaluation of the claim, which we accepted in good faith, believing that they would comply with the Ombudsman's order and the scientific evidence provided.
Rejection of Claim:
Despite the Ombudsman’s order and the medical evidence provided, the insurance company rejected our claim, stating that we failed to provide a letter from the doctor detailing the contribution of smoking to ALK+ve cancer. This demand was unreasonable and not supported by any scientific methodology. ALK+ve cancer is predominantly a genetic cancer that occurs in non-smokers, and there is no established methodology to link smoking as a contributing factor to ALK+ve cancer. Therefore, the rejection of the claim on these grounds is unjustified and appears to be a deliberate attempt to deny the claim on non-existent technical grounds. This was further substantiated by their response stating, "It would be helpful if the treating doctor is able to certify the cause of lung cancer in this case"【source】.
Intentional Delay:
The insurance company and their TPA, Vidal Health, have caused intentional delays in the evaluation of our insurance claim, the processing of the Ombudsman order, and the reevaluation process. These delays have added unnecessary stress and hardship, further indicating their intent to defraud and obstruct justice. Despite multiple requests for clarification and methodology, they have failed to respond appropriately, causing further delays.
Request for Methodology:
We have provided various literature proving that ALK+ve is a genetic cancer and links to research papers that establish ALK+ve as a lung cancer. Despite multiple requests, the insurance company and their TPA, Vidal Health, failed to provide any basis for considering ALK+ve cancer as caused by smoking. When we requested the methodology used to determine the contribution of smoking to ALK+ve cancer, the insurance company wrongfully rejected our RTI application under Section *(f) and Section *(*)(d) to hide the information under the wrong pretext. Subsequently, we filed a first appeal for the RTI application, highlighting why the sections do not apply to the nature of our inquiry. They have not provided the information to prevent exposure of their wrongdoing of adopting non-existent technical grounds because such methodology does not exist in normal practice except in R&D.
Ongoing Complaint to Ombudsman:
We have also filed a complaint with the Ombudsman (Complaint Ref: DEL-MISC-H-***-****-****) regarding this matter. The details of our complaint highlight the insurance company's failure to comply with the Ombudsman's order and their unjust rejection of our claim​​.
Grounds for Filing FIR:
Cheating (Section *** IPC):
The insurance company and their TPA, Vidal Health, proposed a reevaluation to close our legal option through the Ombudsman and then rejected our claim on baseless grounds, amounting to cheating.
Conspiracy (Section ***B IPC):
The actions of the insurance company and their TPA, Vidal Health, suggest a conspiracy to deceive us by first proposing a reevaluation and then rejecting the claim on non-existent technical grounds.
Misrepresentation and Fraud:
The insurance company's and TPA Vidal Health's misrepresentation regarding the reevaluation process and their failure to comply with the Ombudsman's order and scientific evidence indicate fraudulent intentions.
Intentional Delay:
The intentional delay in the evaluation of our insurance claim, the processing of the Ombudsman order, and the reevaluation process further supports the allegation of a conspiracy to obstruct justice and defraud policyholders.
Additional Request for Investigation:
Thorough Investigation of All Ombudsman Cases:
We request a thorough investigation of all cases handled by the Ombudsman where the insurance company and their TPA, Vidal Health, proposed a reevaluation and subsequently closed the case, only to later reject the claim. This pattern of behavior may indicate a broader conspiracy to defraud policyholders.
Expected Conspiracy Details:
The suspected conspiracy involves a coordinated effort between United India Insurance Company Limited and their TPA, Vidal Health, to systematically deny legitimate insurance claims through a series of deceptive practices. These practices include:
Proposing Reevaluation to Close Legal Options:
By proposing a reevaluation, they effectively close the legal option of pursuing the claim through the Ombudsman, misleading the claimant into believing that the reevaluation would be conducted fairly and in compliance with the Ombudsman’s order.
Intentional Misinterpretation of Medical Evidence:
Despite medical evidence and scientific consensus that ALK+ve cancer is a genetic form of cancer predominantly affecting non-smokers, they insist on requiring proof of the contribution of smoking, which is irrelevant and unsupported by medical literature. This is used as a pretext to deny the claim.
Deliberate Delays:
They intentionally delay the processing of claims, the implementation of Ombudsman orders, and the reevaluation process to cause distress and financial hardship to the claimants, hoping they will abandon their claims.
Misuse of RTI Act Exemptions:
By wrongfully rejecting RTI applications under inapplicable sections, they prevent the disclosure of information that could expose their fraudulent practices and lack of valid methodology.
Pattern of Behavior:
This behavior is not isolated. It is suspected to be a pattern where multiple claimants are subjected to the same deceptive practices, indicating a broader conspiracy to defraud policyholders systematically.
Request:
I kindly request you to register an FIR against United India Insurance Company Limited and their TPA, Vidal Health, and investigate the matter thoroughly. I am attaching copies of the following documents for your reference:
The Ombudsman's order (Complaint Ref: DEL-H-***-****-****, Award No: IO/DEL/R/HI/****/****-****)​​.
Doctor's certificate confirming ALK+ve cancer.
Test reports confirming ALK+ve cancer.
Correspondence with the insurance company.
RTI application and their response.
Complaint filed with the Ombudsman (Complaint Ref: DEL-MISC-H-***-****-****)​​.
Thank you for your attention to this matter. I look forward to your prompt action to ensure justice is served.
Yours sincerely,
Deepak Goel
**/*** Heritage City,
MG Road, Gurgaon, Haryana, ******
Contact Number: **********