Apollo Munich Health Care Co Ltd — Denial of Claim

Address:

South West Delhi, Delhi

SUB:- Claim Id 75875 with FHPL TPA
Medicity ID:[protected]
Policy No 110105/1110/[protected] UHID[protected] Apollo Munich Healthcare

Dear Sirs,

I, Sanjay Ahuja, had Family Floater Mediclaim Policy No 354300/38/08/[protected] for a sum of Rs 4,00,000 from M/s National Insurance Co ltd since 2007. I had this policy for 3 years and as you can see no pre-existing diseases were mentioned as well as that no claim was received by them in a period of 3 years. I paid my last premium on 29/11/2010 am amount of Rs 13808/- vide cheque no 605520 drawn of State Bank of India, Inderpuri Branch. This cheque I had sent vide courier and the company said that it did not receive the cheque so my policy was not renewed.

In October 2011, I approached Apollo Munich Healthcare Limited for issuing me a fresh Mediclaim Policy for Rs 5,00,000/- each for myself and my wife separately. At that time the company had conducted several extensive checks to check if my health was perfect or not. I paid a sum of Rs 1350/- to the doctor who conducted the tests and was reimbursed a sum of Rs 425/- after issuance of the policy. My wife who was 55 years at that time also paid Rs 950/- for the tests and was reimbursed Rs 350/- after issuance of her policy.

On 25th April 2012 I experienced heaviness in my chest whilst walking. I took some Gelusil and Eno to relieve my symptoms which continue to persist.

On 1st May 2012 I went to the Local doctor, who prescribed me medicines for acidity.
His prescription was enclosed in my Claim form.

On 4th May I went back to my local doctor since I was not getting any relief, who suggested that I should get a Stress ECHO Test done.

On 5th may I went for the above test to Dr Dhoda’s lab on Pusa Road. My BP recorded before the test was 110/70. While the echo was OK but there was a possibility of Ischemic Heart Diseases.
The report in enclosed in original in the claim form.

I went on 5th Evening to Dr Moshin Wali, HOD Cardiology, Ram Manohar Lohia Hospital. at 4.00pm and upon testing my BP found it to be 164/95. Also he took a random Blood Sugar test using a strip and found my Blood Sugar to be 170. He prescribed Blood Pressure Reducing medicines and Insulin Producing Medicines and Cholesterol reducing medicines apart from Blood Thinning medicines and Nitro Glycerin.

His prescription has been enclosed in original along with my Claim forms.
This is the first time I had been recommended medicines for HYPERTENSION and Diabetes.

He also recommended me to undergo a myocardial per fusion Scan which was done on 10th of May at Delhi Institute of Functional Imaging. This test indicated a 90% blockage in my main artery of my heart. Also a weak heart valve. The report is included in original in my claim form.

I took 2-3 days to consult various doctors and weigh the options available before me before deciding to get an angiography done from Medicity.

I went to Medicity on 15th May at 10.00 am and was examined by Dr Ahmed ,Junior for Dr. R.R. Kasliwal. His prescription is as given below:-


I was admitted on 15th May for Angiography at Medicity and they preformed the angioplasty the same time as I was already in the Cath lab. I had deposited Rs 11000 for Angiography and they asked me to deposit another 115000 for the procedure. I had to deposit another 125000 before the discharge could take place.

When I was discharged on 17th they gave me a copy for the TPA desk which should contain all the relevant documents. This along with other originals was deposited by me in a couple of days to the TPA along with my claim forms duly filled.

The TPA M/s FHPL informed me to get the Certified Case Sheet Reports from the Hospital. I had sent my representative on 11th June to Medicity but he was sent around in circles without any result. I had written to the Doctor Dr R R Kasliwal and he has written back that I can get the concerned documents from the TPA desk.

Sanjay Ahuja ✆
Jun 9 (7 days ago)


to rr.kasliwal, rrkasliwal, info, RAMESH, rnarula63


Dear Sirs,

I Sanjay Ahuja Patient Id no MM00239777 had an angioplasty done at Medanta on 15/05/2012 and was discharged on 17/05/2012.

The Third party Insurance company has asked me for CERTIFIED INDOOR CASE SHEETS from the hospital.
My representative will be visiting the hospital on Monday 11th June at 10.00am to collect these sheets.
He will be meeting you or your juniors for the same.

Kindly arrange to have these sheets ready by then.

Thanking you,

Regards


Ravi R Kasliwal ✆
Jun 9 (7 days ago)


to me


Please send him to TPA counter they are the right person.


Dr R R KASLIWAL
MBBS, MD, DM (Cardiology)
Chairman- Clinical & Preventive Cardiology
Medanta Heart Institute
Medanta The Medicity
Sector 38, Rajiv Chowk
0- [protected], [protected]
[protected]@hotmail.com, rr.[protected]@medanta .org


I then sent the following letter to the TPA authorizing them and the hospital to hand over the case sheets to the T P A. The TPA was able to get the Certified Internal case Sheet reports from the hospital and on 5th July 2012 rejected my claim informing me that “CASE IS REJECTED DUE TO NON DICSLOSURE OF MEDICAL FACTS”

I sought from them the report on which they had based their points and they send me the following document:-


Now the points to be noted here are as under:-

a) I was extensively tested for medical problems by the Previous Healthcare Insurance company as well as by your company prescribed doctor. His ECG and other tests came out perfect and my policy was issued. In case I had been suffering from CAD since the last 10 years, should not it have been detected in my ECG which would have shown siginifant changes?
b) If my intention was to defraud the Insurance company and had I been suffering from CAD since the last 10 years, I would have sought the claim from M/s National Insurance Co ltd and not Apollo Munich Healthcare.
c) I would have filed for the claim within the period of 3 months of obtaining the policy from M/s National Insurance co ltd and not waited till I had actually suffered.
d) The Report of Dr Ahmed, the only doctor who examined me says *HTN (Newly Discovered) and *DM (Newly Discovered) where as the above report on which basis the claim was rejected says “Patient is a know case of HTN and DM and that patient had ? ACS (10 years back)”. Now which prescription or medical history is correct? Even the doctor who wrote this prescription is unsure about his diagnosis as he has put a question mark in his report.
e) The Report on which my claim has been rejected does not carry my name of Patient ID no of Medicity.