Oriental Insurance Company — Official complaint for intentional rejection of claim & not assisting the customer

Address:

Mumbai City, Maharashtra

Oriental insurance policy no;’ policy no : 131102 / 48 / 2015 / 4043

With reference to the above subject, i would like to file an official complaint regarding mediassist & oriental insurance co’ with respect to the below matter.

My uncle, sumanbhai g. Bhodia, a 73 year old, senior citizen, was feeling uncomfortable due to urine retention on sunday (14 - june’15) since 11 o’clock in the morning. Despite several remedies which didn’t work, we finally consulted a doctor at around 9. 45 pm as his pain was becoming unbearable – since his bladder was full. After detailed examination; doctor advised us to get admitted to a hospital for urine catheter. So without a delay, we immediately gathered his mediclaim related documents & called surana hospital, if they assist cashless treatment, since they agreed we admitted him at around 10. 30 pm.

By this time, his condition was getting worst – you can imagine the pain in his abdomen since his gallbladder was full from morning but he can’t urinate. This may have increased his blood pressure too – isn’t it normal to a person who is unable to urinate since morning to night – won’t be there some disturbance in his internal body structure? This can happen to anyone – including you & me. Hence the attending doctor mentioned complaints on admission as: urine retention; breathlessness with bp, severe pain in abdomen & general weakness & they started the treatment. Please note, diabetes, blood pressure, hypertension etc has neither been diagonised for him, nor he ever took any medicines for the same. Trust me, once the catheter was inserted; he was completely relieved & things became absolutely normal including the bp. However doctors need to find a reason behind urine retention in order to cure the same; hence they started medication as per the attending / visiting doctors; advised reports, sonography’s etc which may be a part of their treatment. Please note, neither the patient nor their relatives are ever informed about what reports / medications are been done / given; this happens everywhere.

On the other hand, tpa desk at the hospital was doing their task for getting an approval for cashless. However they request for last 5 years mediclaim policies copy. Since the uncle himself was admitted, it was difficult for us to search previous years copies
Hence i contacted the oritental insurance company & happened to speak with mr. Milind (Sr. Officer) to check if he can arrange copies of previous years which they normally have & can arrange very easily. However mr. Milind without even listening completely, wanted to divert the query to tpa – mediassist. He just kept on saying “you contact ms. Vaishali from mediassist, she will help you. . ” it clearly seems he is not interested to assist customers, then why is he working there? With this sort of attitude of simply diverting queries to another department without even listening or understanding whether the other dept’ could help the client or not.

My question to oriental insurance:
• how could ms. Vaishali from tpa arrange for previous years policy copies?
• why is customers query, not even be heard completely?
• why do we have officers like mr. Milind working for oriental if customer - service & satisfaction is not his motto?
• does senior citizens, take policies for this harassment by not rendering assistance when needed?

Then i contacted ms. Vaishali from mediassist tpa. She said she can’t arrange policy copies – as i always knew.

Meanwhile mediassist had some queries which were responded by the hospital.

A day later, we were shocked when we got a know from the hospital that “cashless was rejected by tpa stating it’s a fresh case & the waiting period is 2 years for hypertensions / bp / diabetes etc”

I contacted mediassist toll free no’ – who said it was denied due to above reason & if i need further clarification, i should contact mumbai office – hence i contacted ms. Vaishali again – who said “she has got an email from oriental insurance to deny the cashless / claim since it’s a new policy. ”

My question to her was “what relevance it has for treating urine retention whether a policy is new or old?”
But she still denied stating “since the patient has hypertension, he couldn’t avail treatments for 2 years which is their waiting period. ”
I tried to explain “the bp / hypertension may only be an incidental finding during admission / treatment however patient neither has any past history of it, nor takes any medicines for the same. The reason for admission was only & only urine retention; anyone’s b. P. Could go high if you are unable to urinate for around 12 hours – that too a senior citizen. ”

My uncle is a sr. Citizen, unmarried lives alone, retired from work & with no source of income. The only reason for getting admitted in surana hospital was because it was in the panel of hospital which assists cashless hospitalization, however the purpose seems to be defeated here since on the other hand, hospital was forcing my uncle to pay.

I spoke to them about the same & they put up the query once again with mediassist explaining that “patient was admitted due to urine retention & not hypertension”

Also to my upset none of the sr. Staff were available to speak from mediassist & oriental on friday, saturday & sunday. I made several calls but no response, or switched off. I was only be able to connect to their tollfree number who said they have no decision making power, i need to contact mumbai offices however ms. Vaishali, mr. Milind, mr. Abhimanyu – none of them answered calls.

Answers from mediassist callcentre “its again rejected saying - since hypertension has been diagnosed they won’t be paying a pie till 2 years for any treatment. ”

It clearly means they just want to see the cash with their comfort angle: hypertension (Reason for rejection) & doesn’t even are interested to understand the actual reason.

I then consulted dr. Aniruddh gokhale (Sr. Urologist) , dr. Vivek maste (Urologist) & dr. Sharad oza to check if hypertension can lead to urine retention? & trust me all 3 of them said “hypertension has not relevance to urine retention – it may only be an incidental finding during examination. High bp does occur during long urine rentention but once releived bp goes normal” which actually happened too.

Vaishali / smita from mediassist told me on saturday that they have a panel of in - house doctors who have checked the case & they have rejected the case, she couldn’t do anything in it.

So my query is:
• are the above doctors (Dr. Aniruddh gokhale, dr. Vivek maste & dr. Sharad oza) incorrect in their judgement that hypertension cannot be a reason for urine retention?

• why was the request for cashless hospitalization rejected when the reason for admission (Urine retention) has no relevance to policy being old / new – it can happen to anyone including you & me – even on the day of buying the policy.

• unlike kidney stone, hernia etc; urine retention isn’t a disease which one can hold for long – in order to get it treated once policy is generated.

• does mediassist & oriental – jointly mean to say “if you buy a new policy & if you suffer from diabetes / bp / hypertension etc – you can’t claim any illness including accident, fever etc for the first 2 - 3 years (Waiting period) even if they have no relevance to each - other.


Please note, i’ve most of the call recordings which happened with ms. Vaishali, mediassist toll free nos, mr. Milind oriental, dr. Gokhale, dr. Maste & other related calls – hence mediassist won’t be able to deny that they rejected only & only due to hypertension which was incidental finding. Also, i’ve preserved supporting emails.

My uncle ideally enrolled for orirental mediclaim policy around 10 years back & all premiums were on time – however due to mishap from punjab national bank staff – last to last year his policy wasn’t generated & created a gap year. I’ll take that seperately with pnb. He holds a active policy in his current year since ocotober’14 vide policy no : 131102 / 48 / 2015 / 4043. To the best of my knowledge he has never claimed anything from the mediclaim & this was the first instance where we required cashless hospitalization but rejected.

Not only claim was rejected but services of mr. Milind / ms. Vaishali / tollfree no’ were not upto mark despite being into service industry. No timely reply on emails. No availability on phone. No listening to customers problems.

My uncle is still under serious mental trauma due to financial crisis created by mediassist tpa & oriental insurance co’. He was not discharged from hospital due to non - payment on one hand & tpa rejection claims on other hand without even knowing the root - cause of admission.
He cried every night after that. Who is responsible for the same?

I wish to take this incident to all consumer forum & courts to assist me in getting justice for my uncle. Will also be publishing it on mouthshut, facebook, twitter & other socializing platforms on the internet so that everyone can know about your pathetic services. Your motto seems to be very clear of only making money via premiums but denying claims without proper reason.


- sameer[protected]