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Lakshmi Narayanan (Software Professional)     08 April 2011

Mediclaim Insurance - Redressal

Hello all,

My family is covered under group mediclaim insurance paid for by my employer. Last month, my father had undergone cardiac procedure where the stents alone had costed 2 lacs at a reputed hospital in chennai(though not a network hospital of the TPA). So, I had to pay the money first and had to get it reimbursed. While filing the claim with the TPA, I had submitted the original bills + medical records + Original stent pouches with the serial number. Now the TPA is asking for the original invoice for the purchase of stents. This hospital always buys Stents in bulk and does not provide individual invoice for each patient. TPA had then asked for "bulk purchased letter" from the hospital which the hospital had refused to give saying they had already given what they need to give. Now, my claim is in the process of getting closed without reimbursement.

Looking for a guidance from the learned members here:

1. What options do I have now if the claim is being rejected? Some of the members have suggested going to ombudsman or consumer forum. Which should I approach first?

2. The TPA is based out of Mumbai, I guess and I am at Chennai. If I were to contest their rejection, should I do that in Chennai or in Mumbai?



 14 Replies

adv. rajeev ( rajoo ) (practicing advocate)     08 April 2011

where your father got the treatment?

First you issue the legal notice to the hospital authorities to asking bill for stents, otherwise instruct them that you would approach the consumer forum.  They may give the detials in their reply, if you got detials then you can produce before the ins., co.,

A V Vishal (Advocate)     08 April 2011

Best option is complain to the Insurance Ombudsman at Chennai. The address of the Ombudsman @ Chenani 

Shri V. Ramasaamy,

Insurance Ombudsman,

Office of the Insurance Ombudsman,

Fathima Akhtar Court,

4th Floor, 453 (old 312),

Anna Salai, Teynampet,

CHENNAI-600 018.

Tel.:- 044-24333668 / 044-24333668 /5284

Fax : 044-24333664

Email insombud@md4.vsnl.net.in

Kumar Doab (FIN)     08 April 2011

 

As adviced by the learned experts/members, initiate your action. Send written communicatins to insurance company,hospital and record everythingwhat has happened.

At the time of admission patient/attendant is suppossed to inform the hospital of the policy and insurance company about the admission.During the treatment hospital usually asks for advance deposit and receipt is issued.At the time of discharge hosapital provides discharge summary and discharge Rx and detailed bill for payment. If the hospital has implanted stent hospital has to charge for it in the bill.

Hosptal is declining to supply the bulk purchase letter since hospital buys at a very low cost, and charges a heavy amount (2Lacs) in your case.TPA knows it and wants to compare the purchase price and sale price.

The hospital shall charge cost of stent+cost of procedure to implant the stent+cardiologist's fee.

You may check in your bill,if 2 lac is fee of stent alone.

You are unneccessarly getting harrassed.

Probabaly your communications with hospital are verbal.Put everything in writing and chronological order with details like date,ti,e ,persom to whom you have represented.

It shall be appropriate if you meet the promoters,MD,CEO of the hospital and explain your plight and ask for their best cooperation to satisfy the insurance company and to get your claim reimbursed, or you shall be forced to go public with your complaint.

You may issue notice to hospital stating due to their recaliterant attitude,unfair practices, you are about to loose your hard earned money and you are already stressed due to disease and financial burden.And if the hospital fails to staisfy the conditions of fair practices and of  insurance company the onus shall be on them.You may highlight that the other employees of your company and your known ones may stay away from the hospital since the hospital does not follow fair practices and cooperate with insurance company.

You may communicate to the insurance company and if required TPA that you have `done your level best and the insurance company may adress their concerns to hospital with a copy to you and there is no delay on your part and your claim can not be refuted.

The policy is group mediclam thru your employer.They must have issued you the iD cards with your address.You can avail treatment at any location.

You may involve concerned HR guy handling the mediclaim,and HR Head.Usually insurance companies provide mediclaim helpdesk executive, who sits in Head Office of the company(your company) to fascilitate the employees.They can exert  pressure on insurance company.Based on the experience they can switch to other insurance  company.They can even send acommunication to hospital.

Lakshmi Narayanan (Software Professional)     09 April 2011

Is there enough grounds to proceed against the hospital when they have already given the original stent covers (with the serial numbers & cost) as also the original hospital bills itemised to reflect the cost of the stent? The insurance TPA is insisting on the original invoice that the hospital has issued during the purchase of the stent from the stent company or a 'bulk purchased' letter from the hospital stating invoice for that specific stent could not be given since the stents are being purchased in bulk.

Kumar Doab (FIN)     09 April 2011

From your latest post it understood that:

1. Hospital doctor felt the need of interventional procedure and looking into the condition of the patient the patient was shifted to cath lab and since stent was readily available, procedure was completed and life threatening situation was averted.

"One human life is heavier than the earth"

Hospital has given the itemized bill and has shown the cost of the stent separately and hence has stated they have done what was needed to be done.

For indoor patients (including critically sick) hospital has its own pharmacy, and patents are given medicines from in house pharmacy (including late hours when the outdoor chemist shops are closed) and cost of medicines is reflected in the discharge bill. The pharmacy is helps to save precious time during critical conditions.

Some hospitals asks the attendants to replace the medicines given from pharmacy, and issues the Rx and patient can take the bill from shop for reimbursement.

The stent covers, having the batch number etc and cost are with you. High quality stents, drug induced stents are imported and their costs are in currency of country where these are manufactured. The stents are imported by Indian company and they paste stickers of their name etc and cost in rupees.

Hospital has charged more than MRP or less? If how much % less than MRP. Usually in India,16-18% is the margin for retailer,8-10% fr stockist,1-2% for CA/CFA etc. Hospital buys direct from company and is usually supplied thru CA/CFA in the same state.

Unfortunately PCR (Price Control regime) is not happening and stents are not in controlled price category.

The cath lab reports show stent was implanted.

2. The TPA is asking for the bulk purchase bill from hospital, which is not in your control.

Hospital shall not want to make the bulk purchase bill, a public document. Stents are highly profitable item.

At  the most you can submit a representation to the hospital and enclosing the TPA's letter and ask to respond and satisfy the insurance company.

At the same time you may reply to TPA that in itemized bill cost of stent has been mentioned and bills submitted by you are in order, hence nothing is pending to be done by you. More over you have done additional work which other wise is not your liability, and have submitted the letter of TPA to hospital, but your claim can not be withheld, since you are not withholding anything.

If TPA has not pointed out anything else, it implies rest of the claim is in order. Still try and obtain a letter that stent is the only query/objection raised.

3. This seems to be cockfight between TPA and hospital.

4. You strongly raise your voice to hospital, insurance company (thru local office and let them exchange communications to wriggle you out of situation), TPA and demand your money, and give a maximum time of say 15 days.

5. The options of legal notice, Insurance ombudsman (since their local office is in your city you can even visit them), consumer forum have already been suggested by learned members/experts.

Bhagavat Upadhyaya (Manager)     06 May 2011

Dear friend,

First of all, obtain the letter / notice from the TPA, stating that if the following queries are not satisfied within a certain period, the claim is likely to be rejected.

Send the copy of this letter to the Hospital Authoroties to comply with it, and if not complied with, the consumer forum may be preferred.

Let me tell you that this may not fall within the operational field of the B.O.

RT.SHANKAR (ADVOCATE)     15 May 2011

I also the same reply of vishal

Best option is complain to the Insurance Ombudsman at Chennai. The address of the Ombudsman @ Chenani 

Shri V. Ramasaamy,

Insurance Ombudsman,

Office of the Insurance Ombudsman,

Fathima Akhtar Court,

4th Floor, 453 (old 312),

Anna Salai, Teynampet,

CHENNAI-600 018.

Tel.:- 044-24333668 / 044-24333668 /5284

Fax : 044-24333664

Email insombud@md4.vsnl.net.in

https://www.law-india.com/

RT.SHANKAR (ADVOCATE)     15 May 2011

Originally posted by :RT.SHANKAR
"


I also the same reply of vishal

Best option is complain to the Insurance Ombudsman at Chennai. The address of the Ombudsman @ Chenani 

Shri V. Ramasaamy,

Insurance Ombudsman,

Office of the Insurance Ombudsman,

Fathima Akhtar Court,

4th Floor, 453 (old 312),

Anna Salai, Teynampet,

CHENNAI-600 018.

Tel.:- 044-24333668 / 044-24333668 /5284

Fax : 044-24333664

Email insombud@md4.vsnl.net.in

 https://www.law-india.com/

 

"

RT.SHANKAR (ADVOCATE)     15 May 2011

Originally posted by :RT.SHANKAR
"



Originally posted by :RT.SHANKAR



"



I also the same reply of vishal

Best option is complain to the Insurance Ombudsman at Chennai. The address of the Ombudsman @ Chenani 

Shri V. Ramasaamy,

Insurance Ombudsman,

Office of the Insurance Ombudsman,

Fathima Akhtar Court,

4th Floor, 453 (old 312),

Anna Salai, Teynampet,

CHENNAI-600 018.

Tel.:- 044-24333668 / 044-24333668 /5284

Fax : 044-24333664

Email insombud@md4.vsnl.net.in

 https://www.law-india.com

 


"

 
"

Bhagavat Upadhyaya (Manager)     15 May 2011

Dear friends,

Here we can examine the issue from a different angle.

Who is answerable to Ombudsman ? Insurance Company or Hospital ?

Who is comotting the default  ? On whose count ?

Infact it is only the Hospital who is not complying with certain norms but it is out of the ambit of Ombudsman.

So, the best way is to serve the notice to the Hospital based on the letter from Insurance Company and after that if you don't get any response you may prefer consumer forum.

Further, even before going to Ombudsman, you are required to give sufficient notice to the Insurance Company,

I advise that without loosing any more time and confusing your self, you start further procedure to aim at the early result.

Jayshree (Editor)     09 November 2011

Hi, I'm working on a related story for a consumer affairs magazine. I would like to know more about your case. Please email me at jayshree.kr@gmail.com

Ramalingam K (Founder and Director of Holistic Investment Planners (P) Ltd. a financial planning nd wealth mgt company. An M.B.A. graduate nd CFP certified professional having 11 years of experience in investment advisory.)     12 November 2011

Apart from term insurance you may also consider a few more points. This checklist will help you taking the right coverage and right policy.

You may check the below link for more and taking the right mediclaim policy.

https://holisticinvestment.in/mediclaim-policy

 

Regards,

RAMALINGAM K. MBA, CFP,

CHIEF FINANCIAL PLANNER,

HOLISTIC INVESTMENT PLANNER PRIVATE LIMITED.

www.holisticinvestment .in

 

Kumar Doab (FIN)     12 November 2011

@ Mr. Ramalingam K

The link suggested by you has been visited. Kindly incorporate comparison of different mediclaim policies.

paragjagda   22 January 2015

Hi all, 

 

I'm reviving this old thread, and this is my first post so please excuse my mistakes if I made any.

 

I'm stuck in a similar situation,

My dad under went a baloono plasty, and the TPA is requesting the original Invoice of the Baloon,

I have submitted all the documents provided by the hospital, and the hospital bill includes the Baloon cost as 1.05,500

On receiving first query letter I went to the hospital and got a photocopy of the Invoice which states the same cost i.e. 1,05,500. The doctor said the original is for their record.

On insisting that we need to original for mediclaim, he stamped the photocopy with the hospital stamp and signed it and gave it to me.

We submitted that to the TPA however they have still send me the same query again.

@Lakshmi Narayanan - Would you please advice on whether you finally got this resolved or had to let go of the claim? If you got it sorted, how did you get it resolved?

Experts, please help, at the earliest.

-Parag Jagda


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