National Insurance rejected cataract claim of a senior citizen on flimsy grounds of policy break-in due to gap of one day in renewal. Moneylife Foundation’s intervention helped him get Rs80,000 from the insurer
National Insurance Company (NIC) has paid Rs80,000 for cataract claim of both eyes to a senior citizen after Moneylife Foundation Insurance Helpline took up the case. In this case, the third party administrator (TPA), had rejected the claim citing one day delay in policy renewal.
It was a case of Heritage TPA (third party administrator) harassment of senior citizen even though they should know the rules of policy break-in. The TPA, while rejecting the claim had stated, “As per Department Office details received, policy is in first year as gap on renewal of policy is not condoned. As per policy terms and conditions, expenses related to cataract are not payable in first year of policy. Hence this claim is non payable and repudiated under clause 4.3.”
The TPA’s letter states that gap of one day in policy renewal was not condoned by the department office. It shows that NIC department office themselves are either ignorant of mediclaim rules or hand-in-glove with the TPA to deny the claim benefits of cataract procedure.
So, gap of one day in policy renewal is wrongly interpreted as if policy is in first year even though the insured was in third policy year. Cataract has two year waiting period and hence the insurer/TPA makes is non-payable with policy as if is in first year due to break-in of one day.
Moneylife Foundation Insurance Helpline reported the matter to NIC corporate office. They immediately emailed to division and regional office to pay the claim.
It is surprising that even after Insurance Regulatory and Development Authority (IRDA) guidelines effective October 2013, TPAs are still settling claims and sending rejection letters. Heritage TPA claims rejection letter to the policyholder is dated 14 November 2013. NIC and Heritage TPA were conveniently trying to reject claim even when the IRDA guidelines are clearly spelt. Will IRDA take cognisance of the TPAs doing business as usual and insurers not taking charge of claims settlement and denial?
Importantly, not many insured are really aware of the IRDA guidelines. Even the policyholder in this case was not aware of it, but was lucky to have approached Moneylife to seek clarity on the issue.
The case also highlights that you may not get condoned for any delay in genuine cases. Insurers are making it stringent for hospitalisation intimation and claims submission after discharge. Will genuine delay be condoned by department or regional office? You can never rely on it.
IRDA had issued renewability of Health Insurance guidelines with effect from 31 March 2009, allowing a grace period of 15 days for renewal of health insurance policies. This grace period was to condone delay in renewal of health policies up to 15 days for the sake of allowing continuity for waiting periods as well as pre-existing disease (PED) cover. However, any loss occurring during the grace period would not be covered as there is no valid insurance contract during the grace period. The grace period of 15 days was increased to 30 days during implementation of health insurance portability guidelines.
It clearly means gap of one day for policy renewal should not have restarted the waiting period for PED (pre-existing disease) or specific ailment. It only means that any claim arising for service done on that one day cannot be paid. It seems to be a silly reason to reject a claim as there is no question to ask for condone for one day gap in renewal. NIC should have paid the claim, but TPA did nothing for six months. Policyholder pleas to Heritage TPA were going nowhere.
These are the cases which make existing prospective customers stop trusting the insurance company, which is one of the reasons general insurance penetration in India is abysmal. There are apprehensions about insurance companies based on unfair claims rejection examples.
Following the arrest of Jignesh Shah in the Rs5,600 crore NSEL scam, shares of MCX tumbled 9.38% to Rs483.55 while FTIL fell 5% to Rs276.70 in early trade on Thursday
Shares of Multi Commodities Exchange of India Ltd (MCX) and Financial Technologies (India) Ltd (FTIL) slumped as much as 9.4% in the morning trade Thursday after the company promoter Jignesh Shah and former MCX head Shreekant Javalgekar were arrested in connection with the Rs5,600-crore National Spot Exchange (NSEL) case.
Reacting to this, shares of both FTIL and MCX opened the day on a lower note. In the early trade, MCX tumbled 9.38% to Rs483.55 while FTIL fell 5% to Rs276.70 – its lower trading permissible limit for the day.
“Financial Technologies chief Jignesh Shah and former managing director and chief executive of MCX Shreekant Javalgekar were arrested in the NSEL case. Both are also members of the board of directors of NSEL and members of the spot exchange’s audit committee,” Rajvardhan Sinha, chief of the Economic Offences Wing of Mumbai Police, had said Wednesday evening.
The total number of arrested persons in the case is now 11. NSEL chief executive Ajnani Sinha had been arrested on 17th October last year.
The FT Group owns 99.99% stake in the now crippled commodities spot exchange which was ordered to be closed by the Government on July 31 last year following a payment crisis.
The arrests came seven months after an FIR was registered by the Economic Offences Wing (EoW) of Mumbai police against Shah (promoter-director of the NSEL) and others on charges of cheating, forgery, breach of trust and criminal conspiracy to make quick profit.
Shah’s arrest is likely to cripple the FTIL and delay its plan to get its 26% stake in the country’s largest commodities exchange reduced to 2%.
MCX and FTIL closed Thursday 6.5% and 5% down at Rs499 and Rs276.7, respectively on the BSE, while the 30-share benchmark ended the day marginally up at 22,376.
Scamsters are now targeting people by using RBI governor, Dr Raguram Rajan's name to announce the big lottery win. The emails also ask people to provide bank details and deposit cash to receive this 'unclaimed lottery fund'!
The Reserve Bank of India (RBI) Governor, Dr Raghuram Rajan has already cautioned people about lottery or beneficiary of fund kinkd of emails. This time, it is a 'Lottery Scheme' email sent using his name in the so-called meeting of 'United Kingdom Lottery Promotion Council' with a 'Senate Tax Committee on Finance', except that both does not exists. Simlar emails used to be sent out in the name of former RBI governor Dr D Subbarao too.
The fake email with attached file, at first, looks like and seems to be an official letter from RBI. The file headlined from the 'Office of the Reserve Bank Of India', New Delhi is sent from the email address '[email protected]'. It reads: "The Foreigh Exchange Transfer Department of the Reserve bank of India have decided to bring to your attention that, you were listed as a beneficiary in the recent schedule for payment of outstanding debts incurred by the United Kingdom Lottery Promotion Counsil, peding since 2007 to 2014. According to our file record with your email id, Your payment is categorized as: contract type: Unpaid Lottery Inheritance fund/undelivered Lottery fund.”
The scamsters have not hesitated to use the RBI governor's name even when demanding 'crediting fees' of Rs15,500, in addition to seeking details like full name, age, sex, address, bank details, etc. The scamsters expect the receiver to be blinded by the prospect of getting quick money as it also provides . But the record is that the only money that has changed hands in 419 scams (advance fee/fake lottery scams) that have been discovered till now, has gone from the victims to such scamsters.
Surely, regular Moneylife readers will find plenty of 'red' signals in such emails. First, the RBI does not use the domain name of “@zh8844.com” for its official emails. Second, even if one assumes that all else is true, why on the earth would the RBI offer money to an individual, and that too in GBP? Third, the RBI does not operate, manage or control any lottery schemes. Fourth, in India, there is no Senate Committee; we have a Parliament and Parliamentary Committees. Therefore, the question of the RBI governor meeting some Senate Committee in RBI's 'branch' in Mumbai/Delhi is not plausible.
Now, let's take a look at some obvious mistakes in the email. The full stops are in the wrong place, capital letters have been used wrongly, as have currency denominations. We use either rupees or Rs or the new symbol, before the amount, while the mail has something else. All it uses is GBP and INR, after the amount-like 15,500 INR or 500,000 GBP. Moreover it also includes photograph of RBI governor congratulating you for winning such prize including latest news sign.
Clearly, this is yet another fraud in progress. So, if you receive such a message delete it immediately.
Earlier also scamsters have sent emails by using former RBI governor, Dr D Subbarao's name. In that scamsters wrote 'secret email' as RBI governor asking people to provide bank and personal details and recieve Rs5.06 core by acting as an individual who died years ago. The email also includes the note asking, “Please note that you will stand as the full owner of the money during the transfer of the money because i will not be among the transfer TEAM, So you are the one to speak with the HEAD OF THE TRANSFER TEAM may be on phone during the time of the transfer. Any money you spend during the transfer will be remove from the money while we share the REST 50-50.”
Here are some points to keep in mind while identifying fake or fraud messages. The scams are widespread, there are many complaint on consumer forum portal, complaintboard.in so RBI and websites like www.truthorfiction.com, www.fraudwatchers.org or www.scambaits.com are giving special attention to this matter, to help potential victims and to catch scamsters. The Reserve Bank of India on its website alerted the public on several occasions about such fictitious schemes/offers through Press Releases in print and the electronic media.
Following mulitiple scams running on RBI's name and its officials, now RBI below its every official email contains the following caution notice,
“CAUTION: The Reserve Bank of India never sends mails, SMSes or makes calls asking for personal information such as your bank account details, passwords, etc. It never keeps or offers funds to anyone. Please do not respond in any manner to such offers, however official or attractive they may look.”
RBI in its Press Release Cautions..
• RBI does not hold any accounts for individuals.
• Beware of impersonated names of RBI officials
• Nobody from RBI calls up people about lottery winnings/ funds received from abroad
• RBI does not send any emails intimating award of lottery funds, etc.
• RBI does not send any sms or letter or email to communicate fictitious offers of lottery winnings or funds received from abroad.
• The only official and genuine website of the Reserve Bank of India is (www.rbi.org.in) and the public may be careful and not get misled by fake websites with similar addresses beginning with ‘Reserve Bank’, ‘RBI’, etc., along with fake logos.
• Inform local police or cyber crime authority about such frauds.
RBI on several occasions in the past, cautioned the members of the public not to fall prey to fictitious offers / lottery winnings / remittance of cheap funds in foreign currency from abroad by so-called foreign entities/ individuals or to Indian residents acting as representatives of such entities/individuals. RBI advised public to register their complaints with the local law enforcement agencies. The Reserve Bank has given the list of such nodal agencies with whom the public can register complaints in its Press Release dated 10 January 2012.
Moneylife always warns its readers not to fall prey for such offers by scamsters and be safe and smart with your money because, "If it looks too good to be true, it usually is."
You may like to read more,
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Number of online frauds high: RBI official
RBI governor latest victim of scam e-mail