Sir,
I have individual mediclaim policy no.152605/48/2011/26
policy issued by City Branch Office of Oriental Insurance Co.Ltd. and TPA was M/s Raksha TPA Pvt. Ltd.
15/5, Mathura Road, Faridabad

The Policy covers the medical risk of myself, my wife and my two dependent children. The policy is about 10 yrs old and since then no claim has been lodged in this policy. This year my son Siddharth Tapadia was hospitalized for treatment of jaundice with Bhargava Heart Hospital and Intensive Care Unit Nursing Home, Ujjain on 12.08.2010. The intimation for the same was sent by fax on 14.08.2010 to Raksha TPA Delhi office as their Indore office fax no. was not working. Since then more than four months have elapsed after submitting all the relevant documents but claim has not been passed yet. Rather they have started irrelevant queries.
Firstly they have said that the intimation for hospitalization was not sent in time and therefore claim cannot be passed. In response to this I have submitted all the proofs of sending intimation along with fax
acknowledgement generated by the fax machine after sending paper to the designated no. as OK report.
There after they kept quite and then send letter asking for certificate of continuation of policy which was also send to them by e-mail by city branch of Oriental Insurance Co. Ltd. immediately . After that nothing
happen for one month when I enquired from Insurance Co., they informed me that the building in which office of Rakha TPA is situated is hit by fire and though the office of Raksha TPA is not affected by fire but their working has been totally disrupted. Hence it will take some time. After few days some Executive of Raksha TPA, Indore called on me on Phone stating that they are processing my claim very soon.However again by letter dated 01.12.2010 they have again ask for certificate of continuation of policy which is already been sent on 27.10.2010 by e-mail. All these working clearly indicates that they are not interested in settling my legal and valid claim which has been lodged well withing prescribed time limit for which proof were furnished to them.The third party administrators asked for all the relevant papers within 7 days of discharge from hospital whereas the post hospitalization treatment upto 2 months is permissible as per policy. Further the certificate of continuation of policy is given by the insurance co. and not by the claiment and despite that the Raksha TPA is asking the same from me repeatatively. This certificate is not required for the treatment of jaundice at all.This clearly indicates that they are not interested in paying the claim but harassing the public at large.
This kind of attitude of third party administrator are creating bad image for insurance co. also and insured persons are suffering because of this TPA's who just want to earn the money and not concern about the well being of the public at large. This complaint is to bring to the notice of all the third parties of
harassment done by TPA's and problem faced by the public at large and to ensure the receipt of claim money as well compensation for mental agony and financial difficulties faced