[Resolved]  Apollo Munich Health Insurance Co. Ltd. — Claim not paid by co. 4 months passed after submission of documents

Address:Ludhiana, Punjab

Respected sir,

Irda token number[protected]
Jagdish kumar suneja-policy no.[protected])

I met with an accident on 9 march and informed company during hospitalization submitted documents in april. In may a investigator mr.Gurnam singh came from delhi to verify documents and doctor records and demanded under table which i refused to pay results of which he submitted company un complete documents company demanded documents which sent to company

Now when company have no option to pay claim. He is demanding documents already submitted.

Point wise reply to all letters / email dated 13.05.2014, 10.06.2014 & 02.07.2014, 21.07.2014 and 07.08.2014.

In last letter dated 07.08.2014, company told no coperation from treating doctor and ask to arrange meeting with doctor which was arranged on 25.08.2014 at 1 pm and mr.Sanjay sharma from lawman associates (Investigator of company) came and checked original records of doctor and collected pointwise reply from doctor on the queries and signed with no more queries left.

Company is continuous avoiding from april. In his email dated 26.08.2014, company committed that there will be final response upto 29.08.2014 but again they send email on 29.08.2014, they need more time to review reports.

If company has not received co-operation from doctor why not intimated in previous letters/email. After 4 monthscompany sayin g doctor not co-operating it is not logic.

Kindly do the needful against apollomunich health insurance company limited.

With regards


Jagdish kumar suneja
[protected]

Enclosed: emails correspondence done with company and documents submitted to company hard copies at its ludhiana office.

[protected]@irda.Gov.In
Dear .Jagdish suneja,


Complaint with irda token number[protected] and entity reference number 108117 has been escalated successfully


Grievance

To me


Dear mr. Suneja,
Greetings from apollo munich.
With reference to your below mail, we would like to inform you that we have got the reinvestigation done on the case and waiting for the final complete report from the investigator.
Post review of the reports we shall be able to share our final decision on the admissibility of the claim as per policy norms.
Request for your patience during the processing time.
For any further assistance, please feel free to write back to us or reach us on our helpline number:[protected].

We candidly submit above resolution against your complaint. You may acknowledge the receipt of this mail and confirm about the closure of the case.
We shall regard the complaint as closed if we do not receive a reply within 8 weeks from the date of receipt of response by the insured /policyholder. Please refer the policy wordings and /or visit our website www.Apollomunichinsurance.com to know the “grievance redressal procedure”.
Thanks & regards,
Narender singh bisht
Asst. Manager ( grievance redressal cell )
Apollo munich health insurance company limited
2nd & 3rd floor, ilabs center, plot no.404-405, udyog vihar, phase-3
Gurgaon -122016, haryana
________________________________________________________________________________...
From: grievance
Sent: tuesday, august 26, 2014 3:47 pm your
To: 'angel suneja'
Subject: re: case id 1075080 policy no [protected]-04

Dear mr. Suneja,
Greetings from apollo munich.
With reference to your below mail, we would like to inform you that basis the details shared by you, we shall contact the treating dr to acquire the required information on subject matter . We shall share our final response maximum by 29-aug-2014.
For any further assistance, please feel free to write back to us or reach us on our helpline number:[protected].
Thanks & regards,
Narender singh bisht
Asst. Manager ( grievance redressal cell )
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Complaint marked as Resolved 
COMPANY REJECTED CASE WITH THESE POINTS : 1. HOSPITALIZATION NOT REQUIRED REPLY: SIR, IF "HOSPITLIZATION NOT REQUIRED" WHY NOT COMPANY INFORMED ME WHEN ADMIT IN HOSPITAL AND WHY DEMANDING DOCUMENTS FOR LAST 4 MONTHS OF HOSPITAL AS ALL DOCUMENTS SUBMITTED ON 28.04.2014 WITH MRI & ALL OTHER DOCUMENTS. EXAMPLE: PATIENT GOT HEART ATTACK SHOULD CONFIRM COMPANY FIRST HOSPITALIZATION REQUIRED OR NOT THEN HE WILL GO TO HOSPITAL. WHEN I INFORM YOU THAT I AM ADMIT IN HOSPITAL WHY NOT YOU CHECKED DURING HOSPITLIZATION. 2. HOSPITAL NOT DISCLOSE RMO NAME & NURSING STAFF NAMES REPLY: DOCTOR ALREADY MENTIONED THAT HE IS 24 HOURS AVAILABLE IF THERE IS REQUIREMENT. HIS SON IS DOCTOR AT C.M.C.HOSPITAL WHICH IS JUST 2 MINUTES WAY. IF HOSPITAL WILL NOT PROVIDE RMO NAME AND NURSING STAFF NAME COMPANY WILL NOT PAY CLAIM ? 3. ETIOLOGY OF PIVD NOT PROVIDED REPLY: DOCTOR ALREADY MENTIONED NO SURGERY DONE AND ETIOLOGY THEREFORE NOT REQUIRED. 4. DISCRPENCIES IN IN-PATIENT RECORDS REPLY: INVESTIGATOR CHECHKED ORIGINAL RECORDS AND IN-PATIENT REGISTER OF 100+ PATIENTS HAVING SAME PATTERN OF PROGRESS NOTES. IT IS DOCTOR PRACTICE AND DULY SIGNED WITH SATISFACTION OF DOCTOR RECORDS. WITH REGARDS, JAGDISH KUMAR SUNEJA 9888888304 ----------------------------- * Mandatory Fields *Name of Complainant JAGDISH KUMAR SUNEJA Communication Details Irda Token number 07-14-019373 *Door No./ Bldg/Name/ Floor 1735-NEW ASHOK NAGAR, Street / Area P.O.NETAJI NAGAR, GURU KRIPA SCHOOL STREET, OPP.GREENLAND SCHOOL, NEAR JALANDHAR BYE PASS CHOWK *City/Town/Panchayath/Village LUDHIANA Taluk/Tehzil District LUDHIANA *State PUNJAB *Pin Code 141008 E- Mail [email protected] Telephone No 86998-35101 *Mobile No 9888888304 Fax No *Insurance Type (Please mentioned Insurance Type ACCIDENTAL INSURANCE *Life * Non Life *Insurance Company Name APOLLO MUNICH HEALTH INSURANCE CO.LTD. *Date of Birth of Policy Holder 22-12-1979 *Policy No: 2000027975 Cover Note: Other Reference No: Policy serving Brach Code/Address FEROZE GANDHI MARKET, LUDHIANA (PUNJAB) *Details of the Complaint (Please type the full details of the complaint) I MET WITH AN ACCIDENT ON 9 MARCH AND INFORMED COMPANY DURING HOSPITALIZATION SUBMITTED DOCUMENTS IN APRIL. IN MAY A INVESTIGATOR MR.GURNAM SINGH CAME FROM DELHI TO VERIFY DOCUMENTS AND DOCTOR RECORDS AND DEMANDED UNDER TABLE MONEY WHICH I REFUSED TO PAY RESULTS OF WHICH HE SUBMITTED COMPANY UN COMPLETE DOCUMENTS COMPANY DEMANDED DOCUMENTS WHICH SENT TO COMPANY NOW WHEN COMPANY HAVE NO OPTION TO PAY CLAIM. HE IS DEMANDING DOCUMENTS ALREADY SUBMITTED. POINT WISE REPLY TO ALL LETTERS / EMAIL dated 13.05.2014, 10.06.2014 & 02.07.2014, 21.07.2014 and 07.08.2014. IN LAST LETTER DATED 07.08.2014, COMPANY TOLD NO COPERATION FROM TREATING DOCTOR AND ASK TO ARRANGE MEETING WITH DOCTOR WHICH WAS ARRANGED ON 25.08.2014 AT 1 PM AND MR.SANJAY SHARMA FROM LAWMAN ASSOCIATES (INVESTIGATOR OF COMPANY) CAME AND CHECKED ORIGINAL RECORDS OF DOCTOR AND COLLECTED POINTWISE REPLY FROM DOCTOR ON THE QUERIES AND SIGNED WITH NO MORE QUERIES LEFT. COMPANY IS CONTINUOUS AVOIDING FROM APRIL. IN HIS EMAIL DATED 26.08.2014, COMPANY COMMITTED THAT THERE WILL BE FINAL RESPONSE UPTO 29.08.2014 BUT AGAIN THEY SEND EMAIL ON 29.08.2014, THEY NEED MORE TIME TO REVIEW REPORTS. IF COMPANY HAS NOT RECEIVED CO-OPERATION FROM DOCTOR WHY NOT INTIMATED IN PREVIOUS LETTERS/EMAIL. AFTER 4 MONTHSCOMPANY SAYIN G DOCTOR NOT CO-OPERATING IT IS NOT LOGIC. KINDLY DO THE NEEDFUL AGAINST APOLLOMUNICH HEALTH INSURANCE COMPANY LIMITED. WITH REGARDS JAGDISH KUMAR SUNEJA 9888888304 *Have you Approached Insurance Company Regarding This Grievance (If Yes Provide Ref No ) From: grievance Sent: Tuesday, August 26, 2014 3:47 PM your To: 'Angel Suneja' Subject: RE: Case id 1075080 Policy no 2000027975-04 Dear Mr. Suneja, Greetings from Apollo Munich. With reference to your below mail, we would like to inform you that basis the details shared by you, we shall contact the treating Dr to acquire the required information on subject matter . We shall share our final response maximum by 29-Aug-2014. For any further assistance, please feel free to write back to us or reach us on our Helpline number: 1800-102-0333. Thanks & Regards, Narender Singh Bisht Asst. Manager ( Grievance Redressal Cell )
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