Insurance denied

I was visiting my son in St Louis, USA, when, suddenly, on August 25, 2005, I met with a medical emergency and was rushed — as per the advice of the doctor — to the Burnes-Jewish hospital under Washington University at St Louis. I was kept in the emergency room there for three days. Tests and treatment were carried out according to the requirements. As soon as I was hospitalised, my son called up ICICI Lombard informing them of my claim number. He was told that in such medical emergencies the entire expenditure is covered as per the policy declarations.

On February 17, 2006, ICICI informed my son that they have processed the claim based on a “policy sub-limit” and that they could review it to ascertain the coverage, and to see if the actual amount claimed by the hospital exceeded such a limit. My son promptly replied that there was no mention of any “policy sub-limits” when the policy certificate was handed over to the insurer.

Now I have been sent a heavy bill ($2156) by Washington University in St Louis (physicians) to my Calcutta address. In a letter dated November 24, 2006, I came to know that a portion of the expenditure incurred while I was in the emergency room would not be covered as it related to “a pre-existing medical condition”, to which I strongly object. I did not have any past occurrences of transient ischaemic attack (TIA) though I have hypertension and Type II diabetes, which necessitated expensive tests.

These tests were undertaken in an emergency condition as the “diagnosis was TIA, not a pre-existing condition, and a life-threatening medical emergency”. This information was also promptly passed on by my son to Dr Rajesh Shukla and subsequently to Dr Kanchan Gupta and Vijaya Pal along with the medical reports.

There was no conclusive evidence leading to TIA. In that case the insurance claim would not have been entertained. Otherwise, the policy should have mentioned that specific diseases would not be covered if candidates had a history of hypertension and diabetes. But for an emergency situation, as the policy dictates, there is no exclusion at all. Would you please guide me as to my next course of action?

Gopal Sakha Mondal, IFS retd.
AE-734, Salt Lake,
Sector-I,
Calcutta-700064

Office of insurance ombudsman: To enable us to admit and process your complaint, the following requirements has to be complied with: The complaint has to be filed without making any representation to the insurance company against their rejection/repudiation order. If the insurance company fails to respond to your representation within one month, this may be intimated to us along with a copy of your representation. If however, the insurance company rejects your representation, a copy of such rejection letter should also be filed with us. On receipt of your response, the matter shall receive further attention.

The Expert: In the present case, the matter in dispute has been taken up with the Office of the Insurance Ombudsman, 29 Netaji Subhas Road, Third Floor, Calcutta-700001 and upon going through the complaint lodged, the Insurance Ombudsman has asked for the following documents:

A complaint has to be filed without making any representation to the insurance company against their rejection/repudiation order. If at the initial stage the insurance company fails to respond within one month, this will have to be intimated to the Insurance Ombudsman with a copy of such representation. However, if the representation made by the consumer has been turned down by the insurance company, this may be forwarded to the Banking Ombudsman for taking necessary steps.

If this fails, the complainant has his remedy before the consumer forum. But the consumer should remember that after the amendment of COPRA on March 15, 2003, to initiate a proceeding before the consumer forum, nowadays, one is required to deposit fees by means of a bank draft.

To know the amount and under whose name the bank draft is to be prepared, one needs to contact the office of the district consumer forum and/or consumer affairs department, the government of West Bengal, or any voluntary consumer organisation that guides consumers free of cost as to how the complaint is to be lodged before the consumer forum and what sort of relief can be obtained under the Consumer Protection Act.

All in a name

On February 28, 2006, I submitted my passport application. After due verification, the application was accepted. At the time of police verification by the DIB office, Burdwan, on March 17, 2006, some additional documents were submitted and the originals produced at the time of verification.

On May 31, 2006, I received a letter from the regional passport office, Calcutta, asking me to submit the PP forms. I had already submitted the forms on June 5, 2006. On July 25, 2006, the DIB Office called up yet again and asked if I had submitted the documents with regard to my birth place. Once again, I submitted all the documents to DIB Office, Burdwan.

After a long wait on October 23, 2006, my representative Subhasis Das visited the regional passport office and talked to the officer concerned (in room number 6 at 11.45 am). He told my representative that the file had not yet been sent to the Howrah DIB office. He handed over a PP form, duly marking in his own handwriting “for SB DIB Howrah J 95/06 PP form submitted on October 28, 2006”.

It’s been a year but I am yet to receive the passport. I am a student and I do need the passport at the earliest. What is my remedy?

Siladitya Das,
Saila Kunja Ramakrishna Palli,
Kalna Road Post and district Burdwan,
West Bengal

Regional passport office: With regard to Siladitya Das’s passport, the applicant applied for a passport with a name which does not tally with his birth certificate. As per the birth certificate, his name is Subhabrata Das, but the application submitted is in the name of Siladitya Das. The applicant has not followed the due formalities for the change of name, which is clearly mentioned in the information booklet of the application form.

For change of name, one has to submit a deed pool affidavit along with two newspaper clips from reputed publications mentioning the applicant’s father’s name and present address. For the change of name, the applicant did not submit the required documents. So the passport could ’t be issued. The passport will be issued only after the completion of name change formalities as stated above.

The Expert: From the reply of the superintendent (administration) of the regional passport office of Calcutta, it appears that the formalities and procedures have not been complied with. The complainant should comply with the guidelines immediately to avoid further hassles and to obtain the passport at the earliest.

All’s well that ends well

This is to inform you that ICICI Bank has blocked my Demat account transaction due to an incorrect entry in the system. How do I get out of the soup?

Arin Dan,
35/2-A, Belgachia Road,
Calcutta-700037

Company response: Arin Dan had written to us citing the problems faced by him and these were investigated. The anomaly was rectified. He was intimated about this and his account is active as on date.
Partha Sarathi Dasgupta,
Branch Manager,
ICICI Bank,
RN Mukherjee Road,
Calcutta.

The Expert: It is good to know that ICICI Bank believes in a consumer friendly approach. All’s well that ends well.