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mediclaim rejected by tpa ghpl


I will really appreciate your advice here.

Last year I was diagnosed with Hypertension. During my pregnancy, Sep 2012, I was hospitalised due to hypertension. Unfortunately we also lost our new born after 4 days. Since then we have seen number of doctors and conducted several tests to understand the cause. Since I have been on medication to control my high BP.

On march 16th due to certain symptoms I learnt that my BP had shot up to 200/140. Doctor was called home who gave me oral medications, but that failed to control it. He advised immediate hospitalisation. At Thunga hospital, doctor advised us to get admitted to an ICU. I was in ICU for 24 hours and during this period I was given some injections to lower my BP; and then was moved to another ward for another 24hours for further observation.

Oral medication billed to some Rs.600 and the remaining was some Rs.14870 was for tests, ICU and other room charges and several doctor visits. My Husband's Group mediclaim through TPA-GHPL  rejected our claim stating the medical bill was only Rs.600 and hence this was only investigative hospitalisation and not active line of treatment. Please advise the next steps and if we should involve a lawyer to fight this case.

Best Regards,

Heena

 
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FIN

 

 

 

First of all you may explain the matter in writing by letter addressed to TPA, Insurance Company, and Mediclaim Help desk/HR personnel responsible for interacting with Insurance Company and obtain a response from the company.

The discharge summary issued by the hospital must have details of the condition of the patient at the time of admission and treatment given in ICU and IPD.

 Obtain the copy of Policy Issued by Insuarance Compnay to Company of your husband inclusing list of exclusions.

A certificate by the doctor who treated the patient at home, recorded the BP and recommended admission may also be referred.

 

The doctor who treated the patient in ICU/IPD can issue emergency certificate and explain the line of treatment.

 

The bill issued by the hospital give itemized detail of charges and charges for ICU and other room charges and several doctor visits should not have been rejected.

 

 

Let the company reply to you in writing.

 

In the meantime you may go thru

 

 

------------INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY

(HEALTH INSURANCE) REGULATIONS, 2012

 

 

-------------GUIDELINES FOR GRIEVANCE REDRESSAL BY INSURANCE COMPANIES

 

-----------IRDA Grievance Redressal Call Centre Toll Free Number is:155255.

 

You can speak to them and understand the matter.

 

---------You may also get in touch with a lawyer specializing in Consumer matters and especially pertaining to Insurance. You can find out about lawyers from local DCDRF.

You may show all docs, give inputs in person, understand the merits before you proceed to file a complaint.

  



Attached File : 78462708 guidelines on grievance redressal.pdf, 78462708 irda health insurance regulation 2012.pdf downloaded 217 times

Total likes : 1 times

 
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Hello Kumar,

Really appreciate your time and the reply. I have partially taken care of the above mentioned advice. The remaining will be done tomorrow. Thanks once again.

Best Regards,

Bhat

 
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