[Resolved]  Medi Assist India Tpa Pvt. Ltd; Oriental Insurance Co. Ltd. — Medical reimbursement denied

Address:

West Bengal

GRV120/1102/2010

ITC Infotech India Ltd

ITC Infotech Park, No 18, Banaswadi Main

Pulkeshi Nagar Post

Bangalore

560005


WITHOUT PREJUDICE
Date:[protected]>


Dear Sir/Madam,

Re:Our Claim No: 1632276 Under Policy No: 431301/48/2010/1340
Policy Holder: ITC Infotech India Ltd Beneficiary: Nabin Ch Maji
Claim Amount: Rs. 44250/- DOA: 23/12/2009 -DOD: 25/12/2009
Hospital Name:NETAJI SUBHASH CHANDRA BOSE CANCER RESEARCH INSTITUTE City Kolkata
AilmentName: case of multiple liver lesions


We refer to your letter dated[protected]in the above connection.

This claim pertains to the treatment of case of multiple liver lesions at NETAJI SUBHASH CHANDRA BOSE CANCER RESEARCH INSTITUTE from 23/12/2009 to 25/12/2009 for the claim amount Rs.44250/- .

We have had a review of the documents by a panel of experts,and as per their opinion, we regret that we are unable to consider your claim for settlement.
The reason(s) are as follows:

AS per discharge summary the insured is admitted to hospital for pain abdomen. As per records it is noticed that Only Investigations done with out any active line of treatment during the period of hospitalization.on verification of indoor case papers it is noted only oral medication advised during admission period and no such related treatment has been done to the patient for which he has been admitted. Instead of basic investigations patient has been directly taken for PETSCAN ( whole body scan) and a small excision of mole over right cheek has been done under local anesthesia. This PETCT Investigations can be done on OPD basis and the diagnosis and treatment given does not co-relate. Patient also claims for the medicine purchased during post hospitilisation period in which major expenses are rendered for protein powder.The treatment is at a hospital which does not confirm to requirements of policy condition .Hence claim stands repudiated under the Op Clause and 4.10 of the policy. We also reserve the right to repudiate the claim under any other ground/s available to us subsequently.

In view of the above facts, we regret that we would not be in a position to consider your request for review of the claim and the claim remains inadmissible for settlement.
We also reserve the right to repudiate the claim under any other ground/s subsequently available to us.The Insured person shall have right to appeal to the Insurance Company if not satisfied with the decision of the TPA.

Thanking You,

Yours faithfully,
For Medi Assist India TPA Pvt. Ltd.

CC:Oriental Insurance Co. Ltd.
CBO-7 HYD,IST FLOOR, JAIN ESTATE, OPP:NANKING RESTAURENT,PARKLANE
Secunderabad-


Medi Assist India TPA Pvt. Ltd. #49, 1 st Main Road, Sarakki Indl Layout, 3rd Stage, J.P.Nagar, Banglore-560 078


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Response to point numbers as indicated/ marked in the Redenial Letter

(1) “..no such related treatment ..’; “.. diagnosis and treatment does not co-relate” :
Response: In accordance to the requirement perceived by the attending doctor at that point of time, admission and supportive care was undertaken for three days. The patient was not in good condition to be able to receive any chemotherapy drugs. Since, the doctor would not give any treatment in excess to the appropriate requirement perceived at that point of time. Thus supportive care taken for these three days, was in fact "active treatment" as perceived by the attending doctor (Dr. R Pandey, MD in Medical Oncology), in order to rejuvenate the health of the patient. Subsequently oral chemotherapy tablets (capecitabine 500mg) have been prescribed, but since they were prescribed, after & outside the duration of admission, I did not submit their bills. Do let me know if these bills are also admissible, then I would submit the same.

(2) “Only investigation done … Instead of basic investigations patient has been directly taken for PETSCAN” :
Response: Preliminary investigations were done on the days previous to the admission, i.e. outside the duration of admission, thus not claimable, hence not submitted along with the claim. USG whole abdomen & Liver Function Test (LFT) were done two days before admission, at SSKM Hospital, Kolkata. Report attached herein.
(3) “The treatment is at a hospital which does not confirm to requirements of policy condition.” :
A case of multiple liver lesions, diagnosed to be malignant in nature, with unknown primary, admitted at an institute dealing exclusively with such cases only. Treatment under a doctor who is an MD in Medical Oncology. There is no disparity or mismatch in the profile of the patient and the treating institute.



Date-wise sequence of events

DATE Place Activity
18.12.2009 “Doctor’s Chamber”, Bansdroni Visited Consultant General Practitioner, for acute abdomen pain. Advised USG abdomen, LFT, and blood tests
21.12.2009 SSKM Hospital Conducted blood tests, LFT and USG abdomen. Tests “allowed free” through a reference MO.
21.12.2009 “Doctor’s Chamber”, Bansdroni Visited Consultant General Practitioner with test reports. Referred to NSC Bose Cancer Research Institute.
23.12.2009 SSKM Hospital Visited SSKM Hospital for second opinion. Referred to oncology & radiotherapy department
23.12.2009
To
25.12.2009 NSC Bose Cancer Research Institute Visited Dr. R. Pandey, MD (Medical Oncology) at NSC Bose Cancer Research Institute. Got admitted for further investigation and treatment.

Name: SANDIP K MAJI
phone: [protected]
email: sandip.[protected]@itcinfotech.com
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