Dear Sir, I met with an accident on 7th February 2013. On investigation at Fortis Hospital it was found that in my right femur fracture has developed. Due to non-tie up with Fortis Hospital & TPA, I could not take the treatment in the said hospital. In investigation I had incurred an amount of Rs. 7356.00. The Bill of the said amount has been submitted to the National Insurance Company while I send the claim on 4th April 2013. I have been admitted for taking the treatment in Paras Hospital on 7th February 2013 where after pre investigation was conducted by them on which they have charged Rs.1100/- towards X-Ray and thereafter they have decided to admit myself in the hospital for operation. The intimation of my treatment was sent to TPA by the hospital and TPA has authorise vide E mail dated 7th February 2013 of Supriya an amount of Rs. 69580/- under GIPSA. I have been in the hospital till 11th February 2013 and on discharge the Hospital has raised the Bill of Rs. 1,30,995/- on me. TPA has finally given the sanction of Rs. 86,722/- for settling the bill. I had paid an amount of Rs.44,273/- from my own pocket. I had submitted my claim of Rs.44,273/- plus Rs. 7356/- i.e. 51,629/- to the National Insurance Company Ltd. Under the above said policy. My case was referred by NICO to TPA. TPA has raised the following queries vide their letter TPA/VA/12/04/2013/313809/1 Dated 12.04.2013, which was replied by me on 19th April 2013 and received by TPA on 20th April 2013 vide their Entry No. 39253 dated 20.04.2013 1. Why Intimation was not given within stipulated time i.e. 7 days. I had given the reply of it that when hospital has informed to TPA and TPA has sanction the preliminary amount for taking the treatment is itself intimation. 2. Asked for submission of Payment Receipt of Rs. 44,273/- I had submitted three receipt as follows: 1. Receipt No. 12-13/165122 dated 07.02.2013 for Rs. 5,000.00 2. Receipt No. 12-13/167720 dated 11.02.2013 for Rs. 28,000.00 3. Receipt No. 12-13/167721 dated 11.02.2013 for Rs. 11,273.00 3. Discharge Summary of Fortis Hospital The reply of the same was given that when I was not admitted in the Fortis Hospital than question of Discharge Summary does not arise.

After one month when I visited TPA office on 28th May 2013, I have been informed that my file is with Dr. Dout in Rohini but when I checked up with Dr. Dout, I was informed by him that he does not have my file and the same was returned to TPA. On checking with TPA on 29th, it was informed to me that my claim is not payable because the payment has been made under GIPSA and if NICO Branch feels that my claim is admissible than only it will be paid by them. I could not understand that when I have the sufficient coverage amount than why the sanction has been given under GIPSA in which limitation is there. You will on it that no perdiction can be made if any person admitted in the hospital that how much amount will be incurred. In policy also nothing has been mentioned about GIPSA. I have the right to take the treatment under the full coverage amount which I did because I have been covered in the policy with sufficient amount of Rs. 2.15 lacs and for the said amount I have paid the premium. I would request you to please settle my claim at the earliest and made the payment to me. I have yet to submit my claim after treatment i.e. Post hospitalisation claim. On settlement of present claim, I will submitted the same. Thanking you, MANOJ KUMAR JAIN