MDIndia Health Insurance TPA Private Limited.

Head Office: S.NO.46/1,E-Space, A2 Building, 3rd Floor, Pune Nagar Rd., Vadgaonsheri, Pune - 411014 (India)
Cashless Tollfree No : 1800-233-4505 Cashless Fax No :020-25300030
Cashless UAN Number (Voice) 18602334448 Cashless UAN Number (Fax) 18602334449
Email : customercare@mdindia.com www.mdindiaonline.com
Dev. / Agent Code : 1D13698872/1D13694373 Date : 25-Mar-2017
To,
Health Manager
THE NEW INDIA ASSURANCE COMPANY LIMITED
MUMBAI RO I - 110000
NEW INDIA BHAWAN 34/38, BANK STREET
MUMBAI MAHARASHTRA 400023 TEL
NO : 22662522/24620316

References :
Claim No : MDI3016567 IC Claim Number : TP005111700169191668
Policy Number : 111700/34/16/28/00001074 Claim Amount : 32190
Patient Name : Mr Madhukar B Mhatre Policy St. Date : 20-Oct-2016
MDI ID Number : MDI5-0031040284 Policy End Date : 19-Oct-2017
DOA : 2-Jan-2017 Hospital Name : NOBLE HOSPITAL

DOD : 4-Jan-2017

Final Diagnosis : UTI WITH LEFT DJ STENT REMOVAL

Subject : Claim Recommendation for Repudiation

As per the instructions of the insurer The New India Assurance Company Limited, the claim is being denied for request of Rs 32190/- on the
following grounds :

We have received the claim documents and on scrutiny of the same, we observe that the claim is not admissible in view of the following.

On Perusal/Scrutiny of above mentioned claim documents, the date of inception 20-Oct-2016 patient treated for UTI WITH LEFT DJ
STENT REMOVAL from 02-Jan-2017 to 04-Jan-2017 .It is Evident that A S PER CLAIM DOCUMENTS IT HAS BEEN OBSERVED THAT INSURED WAS
ADMITTED FOR STONES IN URINARY SYSTEMS & THE TREATMENT FOR STONES IN URINARY SYSTEMS IS EXCLUDED FROM THE SCOPE OF
POLICY FOR TWO YEARS.,Hence the claim is not admissible as per policy clause mentioned. Hence we regret our inability to admit this liability
under the present policy conditions. We wish to point out that you still have right of appeal with the Insurer

The Denial/Repudiation Clause/s with description is/are reproduced below for your ready referenc

Clause No Description

4.3.1
The Claim is Repudiated as - Unless the Insured Person has Continuous Coverage in excess of twenty four months, expenses
on treatment of the following Illnesses are not payable:1. All internal and ext ernal benign tumours, cysts, polyps of
any kind, including benign breast lumps2. Benign ear, nose, throat disorders3. Benign prostate hypertrophy4.
Cataract and age related eye ailments5. Diabetes Mel litus6. Gastric/ Duodenal Ulcer7. Gout and Rheumatism8.
Hernia of all types9. Hydrocele10. Hypertension11. Non Infective Arthritis12. Piles, Fissures and Fistula in
anus13. Pilonidal sinus, Sinusitis and related disorders14. Prolapse inter Vertebral Disc and Spinal Diseases
unless arising from accident15. Skin Disorders16. Stone in Gall Bladder and Bile duct, excluding malignancy17.
Stones in Urin ary system18. Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus19. Varicose Veins
and Varicose UlcersNote: Even after twenty four months of Continuous Coverage, the above illnesses will not be covered if
they arise from a Pre-existing Condition, until 48 months of Continuous Coverage have elapsed since inception of the first
Policy with the Company.
As per the guidelines from regulator, Insurer has right to deny a claim. Hence we are enclosing the complete claim documents herewith for
your review and advice
If you concur with our opinion of denial/Repudiation, you may send the duly signed and stamped denial/repudiation letter to insured which
attached herewith
In case you differ with our observations and reason for denial/repudiation, please return the file with your specific instructions and advice
We continue to remain committed to you as valued customer and assure you the best services at all times
Please return the file with the following remarks for updating our
 Agree with MDIndia recommendation record Not Agreeing for the following

Your sincerely ,
MDIndia Health Insurance TPA Private Limited. Signature and seal of Insurer
 THE NEW INDIA ASSURANCE COMPANY LIMITED
Asian Building D.O. 111700 3rd Floor , R. Kamini Road
Ballard Estate ,MUMBAI-400001

To,
Policy Holder : Mr Madhukar B Mhatre
SAMARTH DHAM, DEVICHA PADA, RETI BANDAR CROSS ROAD, NEAR GAONDEVI
TEMPLE , DOMBIVLI WEST Dist. :
VISHNUNAGAR
MAHARASHTRA
421202

Dear Insured ,
References :
Claim No : MDI3016567 IC Claim Number : TP005111700169191668

Policy Number : 111700/34/16/28/00001074 Claim Amount : 32190

Patient Name : Mr Madhukar B Mhatre Policy St. Date : 20-Oct-2016

MDI ID Number : MDI5-0031040284 Policy End Date : 19-Oct-2017

Hospital Name : NOBLE HOSPITAL
DOA : 2-Jan-2017
DOD : 4-Jan-2017
Final Diagnosis : UTI WITH LEFT DJ STENT REMOVAL
Subject :- Denial of Claim Number - MDI3016567 Under Policy Number - 111700/34/16/28/00001074

We refer to your claim submitted for Reimbursement of Hospitalization expenses to MDIndia Health Insurance TPA Private Limited.

On scrutiny of the same, we observe that the claim is not admissible in view of the following

On Perusal/Scrutiny of above mentioned claim documents, the date of inception 20-Oct-2016 patient treated for UTI WITH LEFT DJ STENT
REMOVAL from 02-Jan-2017 to 04-Jan-2017 .It is Evident that A S PER CLAIM DOCUMENTS IT HAS BEEN OBSERVED THAT INSURED WAS
ADMITTED FOR STONES IN URINARY SYSTEMS & THE TREATMENT FOR STONES IN URINARY SYSTEMS IS EXCLUDED FROM THE SCOPE OF
POLICY FOR TWO YEARS.,Hence the claim is not admissible as per policy clause mentioned. Hence we regret our inability to admit this liability
under the present policy conditions. We wish to point out that you still have right of appeal with the Insurer
The Denial/Repudiation Clause/s with description is/are reproduced below for your ready reference:
Clause No. Description

4.3.1
The Claim is Repudiated as - Unless the Insured Person has Continuous Coverage in excess of twenty four months,
expenses on treatment of the following Illnesses are not payable:1. All internal and ext ernal benign tumours, cysts, polyps
of any kind, including benign breast lumps2. Benign ear, nose, throat disorders3. Benign prostate hypertrophy4. Cataract
and age related eye ailments5. Diabetes Mel litus6. Gastric/ Duodenal Ulcer7. Gout and Rheumatism8. Hernia of all
types9. Hydrocele10. Hypertension11. Non Infective Arthritis12. Piles, Fissures and Fistula in anus13. Pilonidal sinus,
Sinusitis and related disorders14. Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident15. Skin
Disorders16. Stone in Gall Bladder and Bile duct, excluding malignancy17. Stones in Urin ary system18. Treatment for
Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus19. Varicose Veins and Varicose UlcersNote: Even after twenty
four months of Continuous Coverage, the above illnesses will not be covered if they arise from a Pre-existing
Condition, until 48 months of Continuous Coverage have elapsed since inception of the first Policy with the Company.
Since the claim does not fall within the purview of the policy terms & conditions, we regret our inability to admit the claim. If you have any
other information of documents to substantiate admissibility of claim, please provide the same within 15 days of receipt of this letter.
If you are not satisfied with our Denial reason, you may write to our Grievance Cell in our Regional Office or Head office for redressal In
terms of redressal of Public Grievance Rules 1998, you may approach the Office of Ombudsman if you are not satisfied with decision of
company.

Authorized Signatory ,
The New India Assurance Company Limited