After blast in J&K, victim hit by insurance bombshell

Aug 06, 2012, 06:28 IST | Vinod Kumar Menon

Woman forced to stay on in city hospital for several hours after being discharged, as the third party administrator for her medical insurance firm had not cleared her bills

As if losing her mother and suffering severe injuries in a mysterious blast in Kashmir wasn’t traumatic enough for Neeta Jethwa, the 54-year-old was forced to wait around at a private hospital in Mumbai till Saturday evening even after being discharged in the morning, as the third party administrator (TPA) for her medical insurance company had not cleared her bills.

Insult to injury: Neeta Jethwa has mediclaim coverage of Rs 4 lakh, but her cashless claim was initially denied by the third party insurance administrator. Pic/Anita Anand

The Ghatkopar resident was hurt in the explosion on a Tempo Traveller in Anantnag on July 28 that killed four Mumbai women — one of them succumbed to her injuries on August 1 — and wounded seven others. According to Ketan Mehta, a relative, Neeta was admitted to a private hospital in Ghatkopar (W) after being airlifted from Kashmir. She and her husband Bharat have mediclaim coverage of Rs 4 lakh each, and hence it was decided to get the entire treatment cashless.

Dr Mukund Jagannathan, plastic and reconstructive surgeon, who operated on Neeta, said, “Whatever could be done has been done. We have to wait and watch how she recovers post surgery. She will require rehabilitative physiotherapy later.”

However, Mehta and the Jethwas were shocked on August 3, when M/s MD India Healthcare Services Pvt Ltd informed them that they were ‘unable to issue authorisation letter for cashless access for the said patient’ citing New India Assurance’s exclusion clause 4.4.1 — war and war-like perils are not covered under the policy.

“We were aghast with the bizarre reasoning for the denial. There was no war, nor any war like peril that led to the blast. Moreover, J&K police is yet to ascertain the exact cause of the explosion. How did the TPA conclude that there was a war or war-like peril in J&K? This is absolutely absurd,” Mehta said.

Piling on the pain!
According to Mehta, the TPA even failed to provide a satisfactory reply. It was only after Mehta threatened to lodge a complaint with Insurance Regulatory and Development Authority (IRDA) that MD India responded, saying they would study her case again. Mehta added, “Neeta had already lost her mother Nirmalaben Rathod (78) in the explosion, and was also injured herself. The entire family was undergoing tremendous stress and the TPA insurance representatives only added to our pain.”

The Jethwas and Mehta said they are thankful to AD Sarnik, divisional manager of New India Assurance (NIA), who intervened and spoke to the TPA, after which they agreed to clear the claim. However, Mehta said by Saturday evening the hospital had prepared a final bill for Rs 76,163, but the insurance company only cleared Rs 70,723.

“We have decided to file a formal complaint with IRDA and NIA against the TPA,” the family said.

Dr SK Kamath, member of Consumer Guidance Society of India said, “The aggrieved party can approach the Ombudsman of Insurance and can even write a complaint directly to IRDA. The reasoning for rejection of claim by the TPA is absurd.”

The other side
When contacted, Dr Naimuddin Karbari, senior manager (operations) for M/s MD India Healthcare Services Pvt. Ltd, who rejected the claim via an email (copy with this paper), said, “I am not in office and I’ve learnt the claim has been approved now.”

When asked how they concluded there was ‘war and war-like peril’ in J&K due to which they rejected the claim, Dr Karbari said, “I cannot comment on this. I have to study the case in-depth.”

Chaitanya Gujarathi, assistant general manager from M/s MD India Healthcare Services Pvt Ltd, said, “I am out of Mumbai and cannot make any statement.”

Meanwhile, a senior officer from New India Assurance admitted there was indeed a mistake on part of the TPA in rejecting the claim without discussing the same with the concerned divisional officer of NIA. The officer even clarified that clause 4.4.1 is not appropriate for the case and that he would discuss the matter with the TPA and would carry out a detailed probe.

Sushmita Mukherjee, chief regional manager (Mumbai Regional Office–2), New India Assurance, said, “I cannot comment without going through the papers, but we promise to look into the matter.” 

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