[Resolved]  Max Bupa Health Insurance — Denial of Pre-authorization with false statement of pre existent disease when reports clearly showing no existing disease

Address:

Ghaziabad, Uttar Pradesh

Hi Sir, This is with reference to my policy with Max Bupa Life Insurance. Details of the Policy are as follows Customer ID:- [protected] PreAuth ID :- 50929 Patient's Name :- Sudha Mittal Patient is my mother and I, Ankit Mittal, have bought the policy for her. She was disgnosed on 24 June 2014 to have Fibroids and then doctor suggested for operation. Columbia Asia hospital, Ghaziabad, sent mail to Max Bupa on 21st July 2014 for pre-authorization along with all details as required. The operation was scheduled for 24th July 2014 and Max Bupa sent the approval on 22 July 2014. But on 23rd July 2014, Max Bupa decided to reverse there decision on 23rd July 2014 at 10am in the morning when I received the mail that previous approval has been denied now. This was the time when I was at my job in the office. They didn't even left us option to get something done and we were only coordinating with them to get this resolved on phone and mails as only that could have been done from the office at that time. "They stated the Reason for the Denial as follows IN THE PRE-AUTH REQUEST FORM DATE OF FIRST CONSULTAION IS MENTION AS 09/2013.AND POLICY ISTAKEN ON 12/02013.IT SCLEAR THAT AILMENT IS PRIOR TO POLICY INCEPTION HENCE CASHLESS IS REJCTED INPED AND NON DISCLOSER OF PED. PLEASE NOTE PREVIOUSLY AUTHORISED AMOUNT OF RS 70, 000/-STANDS CANCELED We, therefore, request you to kindly contact ANKIT MITTAL with regard to settlement of your bills. In this mater, the customer has been notified today. We request you to share a copy of this letter with customer." I initially notified them that this is due to miscommunication and not all the necessary information to reach to this conclusion. Even my doctor specified this clearly in the preauth details that it was diagnosed only this year in june 2014. She even clarified them everything on her official letter pad which have been sent to them already. Also we are having the reports for the test scheduled 09/Feb/2013 which clearly shows no existing disease regarding the same. We are having all the reports from 2013 to the reports when it is diagnosed first time and confirmed in june 2014. We are continuously trying to share all the information so that have proper information to reach to that conclusion that they have made based on the preauth registration form submitted by hospital. But they are not willing to look at the report neither contacted us before making that decision. Now they are asking for report but when we asking to reply same on the mail they are continuously denying to send any mail update to us stating they reply after 48 hours and not replying even to TPA to which they reply in 4 hours on preauthorization of claims. Further no one is helping from customer care and informing us that sir our preauth team has said this decision can't be changed for whatsoever reason. They are claiming that they have made decision and won't even consider it though we informed we are having reports which clearly shows this is not pre existing disease. They are not helping us on anything now and just trying to delay as much as they can so that we can go under operation ourselves. This have left no option with us and we had tp defer the operation. They just saying decision won't be changed under any circumstance even if report says that or doctor gives on his letter pad and they even rejecting to talk to doctor now. They are not helping us and just delaying the matter and trying to show this as pre-existing disease while we have all the reports which confirms otherwise. We need your help to talk to them, they wont reply neither giving any satisfactory answer, neither saying they want to see reports or talk to doctor, hospital anybody. We will be very thankful to you if you could kindly ask them to check all the reports, consultation and prescriptions to decide if this is pre-existing or not and process are pre-authorization based on it. All the Reports are self explanatory in nature and could help them take sound decision that it is detected and diagnosed only in june 2014. As previously everything was fine regarding it. You can contact us any time of the day through mobile number [protected]. We are available to coordinate with everyone on this issue and want a fair decision which only you can assist us with. Documents Attached:- 1) Pre-Auth Form as filled and sent by Hospital to Max Bupa 2) Patient's ID proof and Max BUPa Card 3) Patient's Ultrasound report dated[protected] reflecting patient diagnosed with Fibroids 4) Doctor's advice showing Patient need operation 5) Doctor's advice dated 9/2/2013, 11/2/2013 and 20/2/2013 showing patient didnt hv the disease pre-existing 6) Ultrsound Report 11/2/2013 clearing reflecting no pre-existing disease. 7) Max Bupa's first approval confirmation letter dated 22 July 2014 8) Max Bupa's denial letter dated 23rd July 2014 9) Doctor's letter on official letter with clear description of ailment not pre-existing. Please look into this as operation is pending on this pre-authorization and we need to get this done so operation can be performed and doesn't get delayed too long. Looking for an early reply from you. Thanks Ankit Mittal