Apollo Hospital — MISCOMMUNICATION, Misconducting by Apollo Hospital Guwahati

Dear Sir/Madam,

This is to inform you that the patient Mrs Mridula Das (AHLGIP23906) was fifth time pregnant (including Twice Post Cesarean Section & Twice Abortion) presented with Bleeding P/V since one month following history of abortifacient drug ingestion over the counter on 27/01/2023. The patient got admitted on emergency basis at 9:27PM on 27/02/2023 during off duty hours of Hospital TPA Desk and initial intimation was sent on 12:45PM on the next day i.e. 28/02/2023. A query was raised after initial intimation which was replied at 6:18PM on the same day. The case was denied for the first time by the insurance company after the said query reply saying the patient is stable. According to treating doctor the diagnosis was under evaluation till the moment of query reply and he was waiting for the Ultrasound report to diagnose the exact cause of bleeding P/V. But he replied the query and filled the initial intimation form, since the attendant was asking repeatedly to the TPA counter and nursing staff on duty. The USG-TVS report suggestive of Retained Product of Conception (RPOC) for which the patient underwent Suction and Evacuation under GA on 01/03/2023. We sent request for reconsideration of the cashless claim at 10:32AM & 3:45PM on 01/03/2023 with all the documents supporting the diagnosis and treatment but denied both times. At last final hospital bill and discharge summary was also sent as final reconsideration at around 7:59PM on the same day i.e. 01/03/2023 after closure of TPA department which was followed up from home by the TPA staffs. The final denial was received at 8:40PM on 01/03/2023 with the denial remark as "Third maternity related charges are not covered as per policy terms hence cashless denied". The hospital TPA team already explained this condition to the attendant of the patient who was an employee of ERIS LIFE SCIENCES during morning hours on 28/02/2023 and advised him to discuss with his corporate HR Team regarding this clause of their policy. During this 48 hours of hospitalization of this patient our TPA Team took written reply from treating doctor thrice, sent documents to her insurance company five times and did follow up with insurance company many times even they worked during their off duty hours and most importantly attendant counselling was done almost 20times including phone calls.

Moreover the attendant of the patient asked several times about the mail body format of communication mails sent by claim book where only patient details reflects (mail copy enclosed), though this question was never raised by any insurance company since they see mainly attachments of the mail for processing of the claims but according to attendant this type of communication will never get approved for cashless. We explained him that this is a system generated mail from our software claim book and Insurance companies only sees the attachments of the mails not the mail body, but he never accepted. It seems his corporate HR team also did not explained him properly about the coverage of his policy neither his insurance company did, so the attendant still believes our communications were not fit for cashless approval, where as his case was denied due to "Third maternity related charges are not covered as per policy terms hence cashless denied".

With regards,

Manager, Credit Desk

Apollo Hospitals Guwahati