[Resolved]  Max Bupa — DENIAL OF CLAIM BEARING SERIAL NO. 213

Address:

Gurgaon, Haryana

Kind Attn. : Shri K. Srinivas

Asst. Director

Insurance Regulatory & Development Authority

Consumer Affairs Department

United India Tower 9th Floor 3-5-817/818

Basheerbagh, Hydrabad-500029



Respected Sir,



I PRABAL GOSWAMI resident of H.N. 706, Sector-10, GURGAON, HARYANA working in BHUSHAN POWER & STEEL ORISSA, want to draw your attention to the under mentioned fact that me as well as my whole family (Wife, my daughter & my son) covered with Health Insurance through MAX BUPA w.e.f. 14/09/2010.



My Wife Mrs. MADHUMITA B. Goswami (POLICY NO. [protected] customer ID[protected] through MAX BUPA) sustains a fall on 11/11/2010 morning. Due to this fall she was having pain while walking but there was no swelling near her hip. Assuming that there is any nerve related problem she was taken to INDIAN INSTITUTE OF SPINAL INJURY CENTER V.K. New Delhi, on 11/11/2010 itself. There Doctor suggested to take MRI for proper Diagnosis. On the basis of MRI report diagnosed as her hip joint has been broken and suggested for the hip joint replacement. Total estimated cost was around 3 to 3.5Lacs. As it was a orthopedic case and INDIAN INSTITUTE OF SPINAL INJURY CENTER V.K. New Delhi, is specialized in nerves treatment, opted for second opinion that is in FORTIS HOSPITAL, V.K. Ned Delhi from Dr. G. Bedi on 12/11/2010. Mr. Bedi has also suggested this same treatment and asked me to admit her on 15/11/2010 as he will be busy on 13/11/2010 and 14/11/2010 for seminar etc.



In the mean time I had taken third opinion from Dr. Sachin Yadav, Lajpat Nagar, New Delhi. As the amount and risk involved was high, finally I decided to take her to FORTIS HOSPITAL, V.K. New Delhi on 15/11/2010 as suggested by Dr. G. Bedi. Accordingly applied for PRE-AUTHORIZATION through FORTIS V.K. New Delhi on 15/11/2010 but till 7PM approval not received. At 8PM when I return back to home along with my wife got a First Massage from MAX BUPA that Pre-Authorization denied and subsequently through Second Mobile Massage informed that they need some more clarification from treating Doctor G.Bedi. Again on 16/11/2010 morning went to FORTIS HOSPITAL, V.K. New Delhi and submitted the clarification through Dr. G.Bedi but ultimately after wasting whole day at 7PM got the final denial massage from MAX BUPA.



As at the time of admission minimum 85% payment is need to be deposited in FORTIS, and at that moment I was not having 3Lacs in hand, return back to home again. From home itself I send a mail to customer care MAX BUPA on 16th Night itself. On 17th I got a call from Ms. PAYAL from MAX BUPA, she inform me that although Pre-authorization has been turned down but reimbursement can be made if I submit the all original bills and all IPD relevant paper within 15days after discharge along with claim form .



Any how I managed to have 3.1Lacs from relatives & friends, admitted her on 18/11/2010. After her discharge on 23/11/2011 all relevant paper sent to MAX BUPA on 29/11/2010 through courier and same was well received on 30/11/2010 by them.



After several calls, inquiries and investigations directly and through their agency M/s. PROBUS ASSOCIATES, ultimately again MAX BUPA refuse to settle the claim, informed through a communication (letter) Dt. 27/01/2011 on false claim ground with mentioning exclusion clause (COPY ENCLOSED).



In reply of that letter Dt. 27/01/2011 I had send a mail on 02/02/2011(COPY ENCLOSED) and given a time of 15days that is up to 17/02/2011 to justify the refusal of claim but till date not received any reply so far.



You are requested to intervene in this matter and take suitable statutory action against the monopoly of MAX BUPA to settle my claim of Rs. 3,09,405.50 with interest due to delay in payment.



KINDLY GRANT ME THE JUSTICE AND SAVE MY FAMILY FROM THE DEBT BURDEN INCURED ON THE TREATMENT OF MY WIFE (INSURED PERSON) THROUGH YOUR OFFICE AGINST FRADULENT DENIAL OF CLAIM (BY MAX BUPA) THROUGH UNLAWFUL AND PREJUDICIAL COMMUNICATION DATED 27/01/2011.



Thanks & Warm Regards



PRABAL GOSWAMI
General Manager - Store's
BHUSHAN POWER & STEEL LTD.
Village : Thelkoloi, P.O. : Lapanga
Tehshil : Rengali, Distt.: Sambalpur – 768232
Orissa (INDIA)
T e l : +[protected],[protected] Extn : 5352
F a x : +[protected], 2562011, 2562016
E - Mail : [protected]@bpsl.net
Website : www.bhushanpowersteel.com

Encl : 1. Denial letter by MAX BUPA dated 27/01/2011
2. Reply sent by me on 02/02/2011

From: PRABAL GOSWAMI
To: Customer Care
Sent: Wednesday, February 02, 2011 9:59 AM
Subject: DENIAL LETTER IN RESPECT OF CLAIM BEARING SERIAL NO.213

KIND ATTN. MS PAYAL

WITH REFERENCE TO YOUR CLAIM DENIAL COMMUNICATION DATED 27/01/2011 FOLLOWING ARE FURTHER ADDED IN SUPPORT OF MY WIFE’S CLAIM.

1. INTIMATE THE EXCLUSION CLAUSE UNDER WHICH CLAIMS DENIED.

2. MRS. MADHUMITA B GOSWAMI TAKEN CONSULTATION FROM THE THREE CONSULTANTS OF THE REPUTED HOSPITALS OF DELHI.

3. ALL THE MAJOR PAYMENTS TO M/S FORTIS, HOSPITAL, DELHI DURING HER TREATMENT (18/11/2010- 23/11/2010) WAS MADE THROUGH CREDIT CARD.

4. SHE HAD INCURRED INJURY AND GOT TREATED AT THE COST OF Rs. 309405.50

5. FROM UR COMMUNICATION WHICH READS AS,"I DECLARE & WARRANT------SHALL BE JOINTLY LIABLE FOR SUCH PAYMENT" FOLLOWING ARE GATHERED

a) SHE HADN'T INCURRED ANY MAJOR INJURY.

b) ALL THE THREE CONSULTANTS OF THREE MAJOR HOSPITALS HELPED HER TO LODGE FALSE CLAIM.

c) EVEN BANKER (ISSUER OF CREDIT CARD THROUGH WHICH MAJOR PAYMENT FOR TREATMENT RELEASED) ACTED ON HER BEHALF AND EXTENDED HELP TO LODGE FALSE OR FRAUDULENT CLAIM.

6) HAD SHE BEEN HAVING FRACTURE SINCE LAST SIX MONTHS, SHE SHOULD NOT HAVE HAIL & HEARTY PRIOR TO SUSTAIN A FALL ON 11/11/2010. BY WHICH MEDICAL REPORT YOU HAVE OBSERVED THAT FRACTURE IS AN OLD FRACTURE & IS NOT IN ACUTE IN NATURE MORE OVER AFTER THE FALL ON 11/11/2010 WHEN SHE UNABLE TO WALK PROPERLY THEN ONLY SHE WAS TAKEN TO INDIAN INSTITUTE OF SPINAL INJURY CENTRE ASSUMING THAT SHE MIGHT BE HAVING SOME NERVES RELATED PROBLEM . WE NEVER IN A IMPRESSION THAT SHE GOT SOME FRACTURE.

IN VIEW OF THE ABOVE YOU ARE NOTIFIED FOR RELEASE OF MY WIFE’S CLAIM AMOUNT WITH INTEREST WITHIN 15 DAYS FROM THE RECEIPT OF THIS NOTICE OTHERWISE I PRABAL GOSWAMI HUSBAND OF MADHUMITA B GOSWAMI SHALL PURSUE THE AVAILABLE REMEDIAL ACTION AS PER THE LAW OF THE LAND AGAINST YOUR FRAUDULENT DENIAL OF CLAIM AND UNLAWFUL AND PREJUDICIAL COMMUNICATION DATED 27/01/2011.

Thanks

PRABAL GOSWAMI
General Manager - Store's
BHUSHAN POWER & STEEL LTD.
Village : Thelkoloi, P.O. : Lapanga
Tehshil : Rengali, Distt.: Sambalpur – 768232
Orissa (INDIA)
T e l : +[protected],[protected] Extn : 5352
F a x : +[protected], 2562011, 2562016
E - Mail : [protected]@bpsl.net
Website : www.bhushanpowersteel.com