Mr. Rajeev Kumar, the complainant has stated that two claims for treatment of his wife had not been settled by the insurance company till date. Aggrieved, he had requested the TPA/insurer including its GRO to reconsider the claims but failed to get any relief. The complainant stated that he had submitted two claims amounting to Rs. 299179 for treatment of his wife to the TPA on 17.01.2017 but in spite of various letters and telephonic calls, his claims had not been settled by the insurance company till date.
The complainant informed that after lodging the complaint in this forum, he had received payment of one of the claims but another claim had not been settled by the TPA/insurer till date. The representative of the insurer stated that in spite of his best efforts, status of the pending claims could not be obtained from the policy issuing office. He requested for some time so as to enable him to get details of the claims lodged by the insured. Accordingly, another personal hearing was held on 17.11.2017. The insurer informed that out of the two claims lodged by the complainant, one claim for Rs. 93881/- had been paid and the complainant had been advised to resubmit claim papers of the second claim as the same could not be traced by the TPA/Policy issuing office at Bangalore.
The complainant stated that he had already sent the claim papers of the second claim to the TPA; however, he agreed to resubmit the same. The insurer informed vide their mail dated 29.11.2017 that the complainant has resubmitted claim documents of the second claim for Rs. 1.73 lakhs to the TPA and the admissible amount of the claim would be settled shortly. It is observed that although, the complainant had alleged inordinate delay in settlement of the claims, he himself was confused and could not provide specific details of the claims. It appears that the complainant had also not followed up the claims properly with the insurer. However, now that the documents have been re-submitted, the insurer is advised to ensure prompt settlement of pending claim.
