Date : 23-Mar-2017

References :

Claim No : MDI2980710

Policy Number : 111700/34/16/28/00001074

Patient Name : Mr Madhukar B Mhatre

MDI ID Number : MDI5-0031040284

DOA : 8-Dec-2016

IC Claim Number : TP005111700169181794

Claim Amount : 134512

Subject : Claim Recommendation for Repudiation
Policy St. Date : 20-Oct-2016

Policy End Date : 19-Oct-2017

Hospital Name : NOBLE HOSPITAL

DOD : 13-Dec-2016

Final Diagnosis : LEFT PCNL + DJ STENTING

As per the instructions of the insurer The New India Assurance Company Limited, the claim is being denied for request of Rs 134512/- 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 LEFT PCNL + DJ
STENTING from 08-Dec-2016 to 13-Dec-2016 .It is Evident that AS PER CLAIM DOCUMENTS IT HAS BEEN OBSERVED THAT INSURED WAS ADMITTED
FOR UTI & IT IS COMPLICATIONS DUE TO STONES IN URINARY SYSTEMS & THE TREATMENT FOR STONES IN URINARY SYSTEMS IS EXCLUDED FROM
THE SCOPE OFPOLICY 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 outthat 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.
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 is
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

Not Agreeing for the following reasons

Dear Insured ,
References :

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 LEFT PCNL + DJ STENTING
from 08-Dec-2016 to 13-Dec-2016 .It is Evident that AS PER C LAIM DOCUMENTS IT HAS BEEN OBSERVED THAT INSURED WAS ADMITTED FOR
UTI & IT IS COMPLICATIONS DUE TO STONES IN URINARY SYSTEMS & THE TREATMENT FOR STONES IN URINARY SYSTEMS IS EXCLUDED FROM
THE SCOPE OFPOLICY 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 outthat 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