Apollo Munich Health Insurance — Mediclaim Rejected

Address:

Mumbai City, Maharashtra

Dear Team, Greeting!! I am Adv. Pradeep Jain customer and shareholder of your company. I have been admitted to Smt. Motiben Dalvi Hospital and diagnose with HSP and according I had lodged the claim with your company under the claim id no. 246448/1 but the same has been rejected with strange or unacceptable reason. The brief fact of my case is under: In the month of August-September, 2014 I was getting swelling, cramps, blood clots ad red rashes on my both the leg and below the knee only. I had went to local Municipal hospital and taken a treatment for 1month but not got any relief then I had consulted to my one Dr. Omprakash Gajelli and he has also treated me for more than 1month but the result is same i.e. no relief and under his reference only I had visited to Dr. Girish Vashwani at Bhatia Hospital for consultancy but upto that time the pain become unbearable and due to blood clots I was unable to stand only and after seeing my this condition Dr. Girish advice me to get it admitted under his supervision at Bhatia Hospital only as my condition is day by day getting degrading. But as I am aware that Bhatia Hospital is too costly so I had requested him to admit me in Smt. Motiben Dalvi hospital as he is visiting consultant over there also and price also comparatively too low. I am admitted in Smt. Motiben Dalvi hospital on 17th Decembe, 2014 and before admission as a intimation call I had given to your call center and requested for cashless facility and they had denied the same and stated that if you are getting admitted in any of the well known hospitals such as Bhatia Hospital, Saifee Hospital then they are having this facilities otherwise they are not having. I had explain my all the treatment to call centers and they had confirm me on call that if am admitting in Bhatia or Saifee they are providing me cash less facility but keeping on the faith of your company I had thought why to waste the amount when I can manage the same in lesser amount, only thing I have to claim for reimbursement. But it was shocking and surprising that my claim amount is rejected and giving a few words reason i.e. “hospitalization is not established only oral medications has given” but you claim department is considering all the claim on one footing only i.e. if I had taken a IV my claim would have been passed but they are fail to understand that if IV is not required then why doctor will give IV to the patient and there are many more reasons for getting admitted in hospital is that swelling, cramps, blood clots ad red rashes from last four months is not enough for getting admitted in hospital and that is also without diagnosing the diseases. And if you can peruse my discharge card the Doctor has given a probability of HSP and he is not firm on his decision and that’s why he has not given me any medicine. After my discharge from Smt. Motiben Dalvi hospital and as per Dr. Gisih advice I had waited for near about 20 days but my condition is not improved and hence I had went to KEM (Government run hospital) with my one of the known doctor Mr. Deshmukh and he has done a doppler and advice me to consult Ms. Rohini Samant (Rymotologist) at Hinduja Hospital she has also given me medicine for 15 days but the condition was same then she advice me to bring some blood reports and xray reports and after that also she has prescribe me medicines but things are constant and then she finally advice me to do a skin biopsy test and if you go through her prescription she has mention probabilities of EN and not sure about that and as a last diagnosis for skin biopsy I had visited to Dr. Salman Bhoira refereed by Mr. Omprakash Gajelli and he had advise me that skin biopsy is not required and prescribe me to do two more blood test and after the report he has prescribe me to start one month course of AKT4 (treatment for TB as my monto test was positive) and he was so confident that he told me that after this course all the trouble will be resolve and accordingly I had completed this course and finally after getting fedup from all this things, I had taken a help of Mr. Deshmukh and he advice me start treatment in KEM hospital only and according I had started and as per their Doctor advice I had done with Biopsy also and some blood test also and as per Skin Biopsy I am suffering from LCV and currently my proper treatment is going on. I am cursing myself that why i had not hospitalize in Saifee, Bhatia or Harkisandas hospitals instead of local hospital, only thing was that in these hospital the expenses would be approx more than triple but it was not going from my pocket and even i was able to opt for cashless facility also and not incurred a loss of thousands of Rupees. The person is not admitted in hospital for the joy, when he can be treated from OPD, in my case it was my condition that’s why I had been forced to get it admitted and about this Dr. Girish has also issue a certificate also. Due to this disease and admission in hospital I was unable to attend my office and incur a loss of more than Rs.1, 00, 000/-. The Doctor has an advice that’s why I had admitted in the hospital otherwise I was taking my treatment from the doctors clinic only. And if doctor is advice then you are not having any other option to obey the same and you can’t endanger your life due to your own negligence. I had incur loss from both the side I lost my revenue and my medical expenses is also not reimbursed. All the aforesaid referred document has been submitted to your claim department and do let me know if you need one more set of this documents. After lodging the claim your TPA has approached to me and he has taken some of my snaps which you can refer to understand the physical condition, that would be really helpful for to pass my claim. One further request is to establish one claim settlement department in your officers where you customer can approach and justify his claim, with your current call center no customer is satisfied as every time they are getting some one new person on the line. In the aforesaid circumstances I request you to pass my claim at the earliest otherwise I am not having any other option to approach the IRDA or to take any other legal recourse to get my claim pass which is 100% genuine. Thanking you, Yours faithfully, Adv Pradeep Jain