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1. Your complaint has been filed on Date: 18 Jul 2010
Please note down your complaint ID: 14975/3/2010 for further assistance.
2. Your complaint has been filed on Date: 18 Jul 2010
Please note down your complaint ID: 14976/3/2010 for further assistance.
3. Your complaint has been filed on Date: 21 Jul 2010
Please note down your complaint ID: 15076/3/2010 for further assistance.
Policy no: 1302/792825012553 Claim No: 4839396 Insured Name: Raj Kumari Claim Status: Denied
R/s,
Consequences I want to describe because under the grave stress conditions I couldn’t manage my professional duties properly, lost peace of mind also suffered economic and physical damage that have been resulted me and my family poor.
What relief I do want?
Rs. 523056.50/- only against the total outstanding i.e. the denied reimbursement amount of Rs. 23056.50/- at this stage including the follow up treatment till 30th April 2010 + Untold Mental and Physical harassment our family have been undergoing since then equivalent to Rs. 500000/-.
Previously mediassist' cancelled their partial cashless approval to ‘Santom Hospital’ and then asked me to file for claim reimbursement and now people at 'mediassist' India tpa ltd. have ultimately denied the reimbursement claim of my dues amounting to Rs.23056.50/-.
Sequence of events is as follows:-
I have been continuously harassed by the 'mediassist' (TPA) and the 'hospital administration' of 'Santom Hospital' (D-4, Parshant Vihar, Outer Ring Road, Rohini, delhi-110085) for the no fault of me. Even being doctors ourselves these people left no stone unturned to keep us in the grave mental trauma. These people out of their well-known corrupt practices and related attitudes of prejudices thought that no one has been left honest in the field of medical healthcare and insurance except themselves only.
On the evening of 11-03-2010 my wife Dr. Raj Kumari fell ill unexpectedly with the symptoms varying from repeated vomiting associated with severe headache and acute vertigo. I myself tried my best at home giving her due care with required medicines (Inj. Emset iv, Inj. Dynapar I'm and cap pentocid DSR orally etc.) and let her take bed rest. But she didn't respond to that medications instead got more severely sick. By the afternoon of 12/03/2010 she stared feeling dizzy along with pain in her neck and developed weakness very quickly after recurrent vomiting and severe headache. Then I decided to get her hospitalized for proper management and needful expert opinion along with due investigations so that she must have been given her due treatment at the earliest possible.
At this point of time I chose 'Santom Hospital' which is situated close to my place of residence. I was familiar to the display board placed at the entrance of that hospital which showed that the cashless mediclaim facility is available with them. I reported their in the causality and asked the attending doctor to please arrange for the required help. He started the needful protocol of treatment after consulting with a physician named Dr.'A. K.Suraka' which constituted recording of vital-parameters and then giving the needful injectables and medications.
Meanwhile my wife was not getting any relief from her severe headache even after 5-6 hours of admission. 'Dr. A.K. sureka' was called on in emergency as the doctor on duty told that her blood pressure was increased due to pain which was fluctuating between 150/90 to 160/100. Dr.'A. K.Sureka' asked the duty doctor to give a medicine named 1 tab. Amlopress-AT along with other medicines.
He also asked about the history of previous illnesses for help in further possible treatment. We told him about her two previous Surgeries: one for the removal of uterus appx. 12 yrs. ago and the second for removal of gall bladder appx. 8 yrs. back. P. T.O - Continued…….
(This had been duly mentioned and declared at the purchase of mediclaim policy at the very first place.)
He then advised for an 'orthopedic assessment cum expert opinion' and sorts the reffrerence of another consultant named Dr.'N. k.Aggerwal' for the purpose. On the second day of admission dated 13-03-2010 Dr. 'N. K.aggarwal' visited, then after carefully examining my wife suggested that my wife was suffering from 'acute cervical spondyloses and osteoporoses' thus he required further investigations which were to be performed on my wife detailing x-rays, blood tests and some specialized tests which were 'utmost necessary' but the facility was not available with the 'Santom Hospital. And 'Dr. Sushma' in charge at the 'Santom Hospital' informed me that those tests alone were to cost more than Rs. 6000/-. All that of the cost involved had to be 'shelled' out by me of my own because the approval from the 'mediassist' was received only for Rs. 5000/- of treatment which was appx. less than two third of the initial intimated estimated cost of between Rs. 14000 to 15000/-. Seeing no choice I had taken my wife to 'Ganesh diagnostic center' in the evening after arranging for that cost of the tests and managed the tests done. Gradually by the third day morning the condition of my wife was improved to the much of the satisfaction with the treatment which she was receiving. On the consensus of both the consultants involved in the treatment of my wife they preferred to discharge the patient (my wife) on 14-03-2010 with follow-up advice on oral medicines and asked to get regular physio-therapy for neck and back pain.
Post discharge I filed claim for reimbursement of the expenditure we had incurred on the treatment. But the people from 'mediassist' India tpa ltd. have ultimately denied the whole claim sighting absurd allegations. Please find below the deniel email letter from mediassist:-
Dear Sir,
Policy no: 1302/792825012553, Claim No: 4839396, Insured Name: Raj Kumari
Claim Status: Denied
Reason: On perusal of the claim documents it is found that patient admitted at Santom Hospital on 12.03.10 for management severe headache with acute vertigo with cervical spondylosis and Hypertension with complaints of severe headache with recurrent vomitings with acute vertigo. On verification of documents it revealed that some variations, which are vital to decide the admissibility of claim, are found. It is observed that as per the statement of husband of patient by the afternoon of 12.03.10 she started feeling dizzy along with pain in her neck, however complain of neck pain, one of the main symptoms of cervical spondylosis nowhere found in any the claim documents submitted by claimant / collected from hospital. It is further observed from final bill dated 14/03/2010 of the hospital that hospital has charged for medicines for Rs.800/- purchased, when breakup of medicines is asked from insured she provided medicine bills of Rs.708/- from Laxmi medicos & shown inability to provide any detail of remaining Rs.92/-. Further, cash memos for these medicines bills are issued on 29/03/2010 after discharge of patient. When documents verified at hospital, no medicine administration chart is found in Indoor Case records to confirm administration of medicines. It is also observed that prescription for Intra Venous fluids and Injection Monocef is found in admission notes, Indoor Case Papers and requisition slips, but bill or proof of purchase for these medicines not provided by client. Moreover no justified indication was found for administration of injection Monocef. On the basis of available facts it is concluded that the claim documents submitted to us have suppressed vital information with ulterior motive to make undue benefits under the policy. Hence, we regret our inability to admit this liability under the present policy conditions. We also reserve the right to repudiate this claim under any other ground subsequently available to us.
Thanks & Regards,
Vanaja (vanajakshibm@mediassistindia.com) P. T.O - Continued…….
R/S,
Here I Pardeep Kumar Grover h/o Raj Kumari (the patient and the insured) would like to seek your kind attention to the facts that originates out of the claim process that I had filled with the ‘Mediassist india tpa ltd.’ along with Point wise Reply of queries raised by ‘Mediassist’ in their denial email letter (above).
Please treat this letter as my ‘Legal Notice’ to:
a. Mediassist India TPA LTD. and b. Reliance General Insurance for the action of filing a lawsuit before a court of law to protect my interests as a policy holder if I / we don’t receive reimbursement within 15 days of receiving this letter/email.
‘Mediassist’ writes: - Reason:
A. On perusal of the claim documents it is found that patient admitted at Santom Hospital on 12.03.10 for:
1. Management of severe headache with acute vertigo;
Answer: True-as patient’s complaints.
2. with cervical spondylosis and Hypertension;
Answer : The above line is ‘hospital’ related part over which we don’t have anything to say, because what his people - attending ‘ BAMS’–RMO’s Writes while putting notes on behalf of their consultants or the opinion expressed by the consultants themselves on the Discharge summery card .
3. with complaints of severe headache with recurrent vomiting with acute vertigo;
Answer: This above half line is unduly ‘repeated’ by mediassist.
(With complaints of severe headache, with acute vertigo) Still it is true-as patient’s complaints.
B. On verification of documents it revealed that some variations, which are vital to decide the admissibility of claim, are found?
It is observed that as per the statement of husband of patient by the afternoon of 12.03.10:
4. She started feeling dizzy along with pain in her neck;
Answer: I Agree –Husband.
5. However- ‘complaint of neck pain’ one of the main symptoms of cervical spondylosis ‘Nowhere’ found in any of the claim documents submitted by claimant / collected from hospital.
Answer:
Totally False - Dr. A. K. Sureka Consultant (in charge) Physician wrote in his notes on his very first visit in the evening: “Neck movements pain full” as he noticed in his clinical observation cum examination. Immediately he involved an experienced orthopedic surgeon named Dr. N. K. Aggarwal for the required expert opinion to discussed further course of treatment. Can you tell me why nobody from mediassist took pain to visit the patient and verify the facts upon & after request for pre-authoriastion intimation by Santom Hospial?
(See attachment of scanned hospital original file- Page no.3.)
P. T.O - Continued…….
C. It is further ‘observed’ from:
6. ‘Final bill’ dated 14/03/2010 of the hospital that ‘hospital has charged’ for medicines for Rs.800/- purchased, when breakup of medicines is asked from ‘insured’ she provided medicine bills of Rs.708/- from Laxmi medicos & shown inability to provide any detail of remaining Rs.92/-
Answer:
You ‘already’ know ‘as you observed’ that as ‘hospital has charged’ for medicines for Rs.800/- O. K? Because: Previously ‘Santom hospital’ was in touch with your (mediassist) people for this case as cash less facility. So was itself arranging for all the medications themselves and we as a patient in trouble didn’t bother at that time. Post discharge: we communicated your office for reimbursement of medical expenditure. As we were not the experienced mediclaim liaison experts, That’s why after your demand of those details of the bills for which hospital had charged Rs.800/-from us for medicines purchased by Santom Hospital from chemist, I contacted- Dr. Sushma in charge ? owner of the hospital, further she ‘then’ arranged the receipts from their ‘Santom Hospital’s chemist Laxmi medicos for the related bills for which hospital had charged’ and I had paid during that critical period of my life when my wife was ‘seriously sick’ and was undergoing her treatment. As I had paid to Dr Sushma. So she (Dr. Sushma) arranged and provided those medicine bills of Rs.708/- in place of Rs. 800/- Here ‘I quote’ she ‘Dr. Sushma’ in charge ? Owner of the hospital not me or my wife as a patient never ever shown any inability to provide the details of remaining Rs.92/-. Also please also note the fact that we have never insisted to reimburse Rs. 800/- instead I always calculated Rs. 792/- only from the very beginning of my request for claims totaling to Rs. 23056.50/-only.
“Still” you can’t deny the fact that my wife –the patient Raj Kumari was neither sick nor hospitalized or never got her treatment as an IPD patient of Santom hospital with Admission No. 255179.
7. Further, cash memos for these medicines bills are issued on 29/03/2010 after discharge of patient:
Answer:
Communication for reimbursement consumed that period of delay from the discharge of the patient i.e. from 14-03-2010 up to 29/03/2010. And after this gap when I had contacted Santom Hospital’s chemist’ through Dr. Sushma he said that this undue gap period of delay was on hospitals part because they didn’t ask for the bills earlier, and that is why the bills are issued on 29/03/2010.
‘Still’ the ‘chemist’ has mentioned the actual dates i.e. 14/03/2010 as well on the cash memos issued.
8. Medicines purchased on those bills include that were advised on discharge slip.
Answer:
As per policy’ mediassist is bound to reimburse the actual expenditure of treatment till two months even after discharge from hospital. So can’t deny the fact that my wife –the patient Raj Kumari was neither sick nor hospitalized or never got her treatment as an IPD patient of Santom hospital with Admission No. 255179.
D. When documents verified at hospital:
9. “No” medicine administration chart is found in Indoor Case records to confirm administration of medicines.
Answer: Plain nonsense with an ‘absurd’ allegation by mediassist.
See attachments of:-
1. Scanned original Certificate issued by-Dr. Sushma in charge? Owner of the ‘Santom Hospital’.
2. Scanned original copies of the Medicine Administration Chart.
P. T.O - Continued…….
E. It is also observed that:
10. Prescription for Intra Venous fluids and Injection Monocef is found in admission
Notes, Indoor Case Papers and Requisition slips, but bill or proof of purchase for these medicines not provided by client.
Answer:
Totally False: As I never purchased any medicines myself during hospitalization of my wife (Raj kumari), It was ‘Santom Hospital’ who was arranging all those medicines.
And the ‘Fact’ is that Santom hospital has provided all the related bills (Rs. 2800/-) for the medicines that were dispensed from the hospital itself. All those bills have already been submitted very early.
(See attachment of the same)
F. Moreover no justified indication was found for:
11. Administration of injection Monocef.
Answer: Absurd ‘allegation’ once again:
Who am I or the patient in trouble to ask the treating doctor? That which injection and why he is prescribing for the ailment of a patient who has reported in the causality struggling for her life who presented in grave seriousness with the symptoms of severe debilitating illness causing threat to her life.
Still as a matter of fact whenever a patient with the kind of symptoms similar to that of my wife got hopitalised, the attending physician remains authority and decides to prescribe the medication according to his clinical observation and relevance.
A patient can’t choose the medicines being administered in the course of her/his treatment.
G. On the basis of available facts:
12. It is concluded that the claim documents submitted to us have suppressed vital information with ulterior motive to make undue benefits under the policy.
Answer:
As every excuse made to refuse the due reimbursement has been suitably addressed and actually nullified the misplaced facts. It is obvious that all the absurd allegations made with the ulterior motive to save a little bounty out of worst ever cries of a women in trouble by Mediassist are actually baseless and a nonsense lie.
13. Hence, we regret our inability to admit this liability under the present policy conditions.
Answer:
You must at the earliest possible without diluting the facts further, admit that you are a cheater but need to admit this liability under the present policy conditions.
14. We also reserve the right to repudiate this claim under any other ground subsequently available to us.
Answer:
I too reserve the right to sue you for not fulfilling this claim liability reimbursement under the ground reality available to mediassist or everyone concerned.
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