-------------------------------------------------- DRAFT FOR ATTORNEY REVIEW ONLY — NOT LEGAL ADVICE This Insurance Dispute Letter is a structured preparation document only. The rebuttal arguments represent the Claimant's own position and are not a professional legal opinion. Independent legal advice from a qualified Indian insurance attorney must be obtained before this letter is sent. This letter does not guarantee any claim or dispute outcome. -------------------------------------------------- Sunita Desai [Full address], Mumbai Maharashtra India [Phone] | [Email] Date: June 1 2026 The Senior Claims Manager New India Assurance Co Ltd Mumbai Branch [Branch address], Mumbai Maharashtra India SUBJECT: FORMAL WRITTEN DISPUTE OF CLAIM DENIAL — POLICY NO. NIA-HLTH-2024-334521 — CLAIM REF: [original claim ref] — DENIAL LETTER DATED MAY 5 2026 — EMERGENCY HOSPITALIZATION CLAIM INR 1,85,000 Dear Sir/Madam, 1. OPENING AND FORMAL DISPUTE STATEMENT I write to formally dispute New India Assurance Co Ltd's decision communicated in its denial letter dated May 5 2026 to reject my health insurance claim under Policy Number NIA-HLTH-2024-334521. I consider this denial to be factually incorrect, without valid basis under the policy terms and applicable IRDAI regulations, and contrary to New India Assurance Co Ltd's regulatory obligations as a licensed insurer. I demand immediate written reconsideration of this decision and full payment of my claim of INR 1,85,000. 2. BACKGROUND AND ORIGINAL CLAIM SUMMARY 2.1 On April 19 2026 at approximately 2:00 AM I was admitted as an emergency patient to [Hospital Name], Mumbai Maharashtra India following a sudden cardiac event. I was admitted directly to the ICU in an unconscious state. 2.2 I submitted my health insurance claim under Policy Number NIA-HLTH-2024-334521 for INR 1,85,000 being total hospitalization and treatment costs on April 20 2026. 2.3 The hospital's TPA desk intimated the Third Party Administrator on April 20 2026 within 24 hours of admission as required under applicable procedure. 2.4 I cooperated fully with the TPA and insurer's documentation requirements and submitted all required documents. 3. INSURER'S STATED DENIAL GROUNDS New India Assurance Co Ltd's denial letter of May 5 2026 states the following grounds for denial: 3.1 Ground 1: Pre-authorization for hospitalization was not obtained before admission. 3.2 Ground 2: The policy requires prior approval before planned hospitalization. I dispute both denial grounds in full as incorrect and inapplicable to an emergency admission. 4. POINT-BY-POINT REBUTTAL OF EACH DENIAL GROUND 4.1 REBUTTAL OF GROUND 1 — Pre- authorization not obtained: This ground fails entirely on the facts. I was admitted to the ICU unconscious following a cardiac event at 2:00 AM. It was physically and medically impossible for me to obtain pre-authorization before admission. IRDAI circular guidelines on health insurance expressly provide that in cases of emergency hospitalization where the insured is admitted in a life-threatening condition, the requirement for pre-authorization does not apply. The hospital intimated the TPA within 24 hours of admission as required for emergency cases. The applicable IRDAI emergency hospitalization pre-authorization exemption provisions must be confirmed with a qualified Indian attorney. 4.2 REBUTTAL OF GROUND 2 — Policy requires prior approval: This ground misapplies the policy term. The prior approval requirement in the policy applies to planned elective hospitalization, not emergency life-threatening admissions. Applying a planned admission requirement to an emergency cardiac ICU admission is a misinterpretation of the policy scope and contrary to applicable IRDAI health insurance regulations. The attending cardiologist's certificate confirms the admission was a medical emergency requiring immediate intervention. No reasonable insurer could apply a planned hospitalization pre-authorization condition to an emergency cardiac ICU case. 5. POLICY TERMS AND COVERAGE ANALYSIS 5.1 My policy covers hospitalization expenses including emergency hospitalization under the Hospitalization Benefit section. 5.2 The pre-authorization condition in the policy must be read consistently with IRDAI regulations which exempt genuine emergency cases from the requirement. 5.3 Applying the pre-authorization exclusion to this emergency admission is contrary to the reasonable expectations of a health insurance policyholder and applicable IRDAI regulatory guidance. 5.4 Note: Policy coverage and exclusion analysis must be confirmed with a qualified Indian insurance attorney. 6. COUNTER-EVIDENCE AND SUPPORTING DOCUMENTS I enclose the following counter-evidence with this dispute letter: 1. Hospital emergency admission record confirming 2:00 AM emergency arrival and direct ICU admission on April 19 2026. 2. Attending cardiologist's certificate confirming life-threatening cardiac emergency and immediate ICU requirement. 3. TPA intimation acknowledgment confirming notification within 24 hours of admission on April 20 2026. 4. Copy of applicable IRDAI circular guidance on emergency hospitalization and pre-authorization exemption. 5. All original hospital bills and treatment records totaling INR 1,85,000. 7. INSURER'S REGULATORY AND GOOD FAITH OBLIGATIONS 7.1 New India Assurance Co Ltd as a licensed insurer regulated by IRDAI is obligated to handle claims fairly, promptly, and in good faith in accordance with the Insurance Act 1938 India and applicable IRDAI regulations. 7.2 Denying a valid emergency hospitalization claim on a pre-authorization ground inapplicable to emergency cases may constitute a breach of fair claims handling obligations under IRDAI regulations. 7.3 Note: Applicable IRDAI claims handling regulations, bad faith insurance handling provisions, and available remedies under Indian insurance law must be confirmed with a qualified Indian attorney. 8. DISPUTED CLAIM AMOUNT I dispute the total denial of my claim. The full disputed amount is INR 1,85,000 being my total emergency hospitalization and cardiac ICU treatment costs at [Hospital Name] Mumbai for the period April 19 to [discharge date] 2026 under Policy Number NIA-HLTH-2024-334521. 9. RECONSIDERATION DEMAND AND DEADLINE I formally demand New India Assurance Co Ltd reconsider its denial decision and provide a written reconsideration response within 14 days of the date of this letter. The insurer must either: 1. Approve full payment of INR 1,85,000 with a payment timeline; or 2. Provide a revised written explanation of continued denial with full factual, policy, and legal basis for each remaining denial ground. 10. RESERVATION OF RIGHTS I expressly reserve all rights as a policyholder under Policy Number NIA-HLTH-2024-334521, the Insurance Act 1938 India, and applicable IRDAI regulations including the right to obtain independent legal advice, commission further expert medical opinion, add supplemental disputed items, and pursue all available legal and regulatory remedies. Nothing in this letter is a waiver of any right. 11. ESCALATION WARNING If New India Assurance Co Ltd does not provide a satisfactory written reconsideration response within 14 days I will without further notice: 1. Lodge a formal complaint through the IRDAI Integrated Grievance Management System IGMS at igms.irda.gov.in. 2. File a complaint before the Insurance Ombudsman for the Mumbai region under the Insurance Ombudsman Rules 2017 India. 3. File a consumer complaint before the Consumer Disputes Redressal Forum in Mumbai under the Consumer Protection Act 2019 India. 4. Seek independent legal advice and pursue all available legal remedies. 12. CLOSING AND CONTACT I am available to provide any further documentation or attend a review meeting with a senior claims officer. Please acknowledge this formal dispute letter in writing at your earliest convenience. Phone: [phone] Email: [email] Yours faithfully, Sunita Desai Date: June 1 2026 Signature: ________________ Enclosures: As listed in Section 6. -------------------------------------------------- This Insurance Dispute Letter draft was generated by an AI drafting tool as a structured preparation and documentation aid only. It does not constitute legal advice, does not guarantee any claim or dispute outcome, and is not a substitute for guidance from a qualified Indian insurance attorney. IRDAI emergency hospitalization regulations and available remedies must be confirmed before sending. --------------------------------------------------