At the time of policy inception in 2011, the pre-existing disease was declared to the Insurer. And based on that declaration, the initial policy document that was issued contained a Co-payment clause of 20% for the patient in question – Mrs. Jharna Das. For the other members in the Group policy (i.e. myself & my father Mr. Ganesh Das) no Co-payment clause was defined. I’m attaching a copy of both the declaration mail i sent before policy inception & the original policy & terms & condition doc copy for your kind review. The mail was sent to Insurance Agent – Mr. Rahul Dadha of Karvat Healthcare as well as Healthfirst India ID that was provided by him. In the mail, not only is the pre-existing disease declared & actively administered medicine names provided, but also ID proofs are furnished for inception of an additional policy. Both these policies have been in effect since June 2011. Any documents, that were ever requested by National Insurance / DHS / Karvat Healthcare, were all provided by us, mostly as hard copies. Per the policy any pre-existing disease was not to be covered for initial 2 years of coverage but was to be covered fully later on. As you’d see from the policy copies attached, policies for 2011 & 2012 (initial 2 years) have a 20% copayment clause for the patient in question, but thereafter even the 20% co-payment clause has been dropped. The first claim on this policy has been raised after 3 years of claim free period, in 2014. Unfortunately, this claim was denied. National Insurance/Health First India has rejected the claim citing two reasons – (1) Non-Disclosure of pre-existing disease. This is incorrect based on facts described above. (2) They also cited a section 4.1 of the Terms & Conditions document indicating that any ‘Genetic’ diseases are not covered in policy. But the original terms & conditions have nothing like that specified. Hence that is wrong as well. The insurer is wrongly & unlawfully denying the claim to our patient, which is putting her treatment & life at risk, additionally causing us Mental Harassment. We would like to request the Insurer to pay the full amount of the treatment as per the Latest Policy Sum assured eligibility, i.e. INR 4 Lakhs/yearly plus damages worth INR 20 Lakhs caused due to Mental Harassment.
* INR 4 Lakhs/yearly (the annual Sum Assured amount for treatment as per policy) * INR 20 Lakhs caused due to Mental Harassment.
Email Id: brijeshgeek@gmail