[Resolved]  Medicare Tpa Services (I) Pvt. Ltd. — Cashless accord

I give below the abstract of correspondence with Sr. Manager of MEDICARE TPA SERVICES (I) PVT. LTD. CALCUTTA,which is self explanatory:


Re: denial letter of M Jasani‏
From: abhishek aditya (abhishek.[protected]@medicaretpa.co.in)
Sent: 17 February 2010 14:10PM
To: Mahendra Jasani ([protected]@hotmail.com); the new india assurance co.ltd. mumbai (bijay.[protected]@newindia.co.in); helpline medicate ([protected]@medicaretpa.co.in)
Cc: debjani.ray customer care ho (debjani.[protected]@medicaretpa.co.in)

Dear Sir



The policy is in force from 2008 & in 2007 (prior to policy inception) you have undergone Cataract Surgery of the right eye. The present ailment, Right Eye Posterior Capsular Opacification, is complication of the cataract surgery in 2007. Thus the present ailment is a complication of pre-existing disease.



The policy does not cover pre-existing diseases or their complication & hence the present claim is outside the scope of policy coverage.



We regret our inability to accord cashless. Please feel free to contact us for any further clarification



Thanks & Warm Regards

Abhishek Aditya

Sr. Manager – Claims






----- Original Message -----

From: Mahendra Jasani
To: Sr. Manager, Medicare HO Kolkatta ; the new india assurance co.ltd. mumbai ; helpline medicate
Cc: debjani.ray customer care ho
Sent: Wednesday, February 17, 2010 1:59 PM
Subject: RE: denial letter of M Jasani

My first Policy is in force from 3rd January, 2008
and My Certificate No. 130100/48/538337/531685/140772, dagted 03/01/08
and policy period: 03/01/08 to 01.01.09

I have no policy in 2007 so the previous claim (in 2007) was NOT settled by the Insurance Co., (which I have already cleared in my previous email). This is for your information.

I submit all 3 policy to your Mumbai Office.

Thanx

Yours faithfully,


Jasani Mahendrakumar

From: abhishek.[protected]@medicaretpa.co.in
To: [protected]@hotmail.com; bijay.[protected]@newindia.co.in; [protected]@medicaretpa.co.in
CC: debjani.[protected]@medicaretpa.co.in
Subject: Re: denial letter of M Jasani
Date: Wed, 17 Feb 2010 13:01:08 +0530

Dear Sir

Can you please confirm since when the policy is in force & whether the previous claim (in 2007) was settled by the Insurance Co.

Thanks & Regards
Abhishek

----- Original Message -----
From: Mahendra Jasani
To: Sr. Manager, Medicare HO Kolkatta ; the new india assurance co.ltd. mumbai ; helpline medicate
Cc: debjani.[protected]@medicaretpa.co.in
Sent: Wednesday, February 17, 2010 12:59 PM
Subject: RE: denial letter of M Jasani

Dear Sir:

I have no any policy before 2008 and I operated for cataract with my own expenses, and I submit the Receipt and Doctors paper to Ms. Sharmeela and she forward the papers to you for your ready reference. I think it is sufficient for you and consider my cashless accord.

Thanking you,

Yours faithfully,

Jasani Mahendrakumar

From: abhishek.[protected]@medicaretpa.co.in
To: [protected]@hotmail.com; bijay.[protected]@newindia.co.in; [protected]@medicaretpa.co.in
CC: debjani.[protected]@medicaretpa.co.in
Subject: Re: denial letter of M Jasani
Date: Wed, 17 Feb 2010 12:45:36 +0530

Dear Sir



As per the date provided to us with regards to your policy, the same is effective from 2008. Since the primary cataract surgery was in 2007, which is prior to the effective policy paper we were unable to accord cashless. The settlement details provided by you do not indicate the policy number nor does it specify that the claim was settled in respect of the Union Bank Policy.



In case your have the policy papers prior to 2008, kindly provide the same to enable us to proceed further with your cashless.



Thanks & Regards

Abhishek Aditya
Sr. Manager - Claims

----- Original Message -----
From: Mahendra Jasani
To: abhishek.[protected]@medicaretpa.co.in ; the new india assurance co.ltd. mumbai ; helpline medicate
Sent: Wednesday, February 17, 2010 12:36 PM
Subject: RE: denial letter of M Jasani

From: [protected]@hotmail.com
To: abhishek.[protected]@medicaretpa.co.in
Date: Wed, 17 Feb 2010 12.33

Dear Sir:

With reference to your email, my Membership Id: 02I00837013B and My Certificate No. 131200/34/09/81/00000001, dated 22.12.09. I have already talked to Ms. Debjani Ray and given her my Membership no.

Thanx and with regards,

Jasani Mahendrakumar
From: abhishek.[protected]@medicaretpa.co.in
To: [protected]@hotmail.com
Subject: FW: denial letter of M Jasani
Date: Wed, 17 Feb 2010 12:03:26 +0530

Dear Sir

Kindly provide your policy / membership no to enable us to trace the claim details.

Thanks & Regards
Abhishek Aditya
Sr. Manager - Claims



[protected] Forwarded message[protected]
From: Mahendra Jasani <[protected]@hotmail.com>
Date: Feb 17, 2010 7:30 AM
Subject: FW: denial letter of M Jasani
To: medicareho calcutta <[protected]@medicaretpa.co.in>

just a REMINDER I .....

PLEASE REPLY

From: [protected]@hotmail.com
To: [protected]@medicaretpa.co.in
Subject: FW: denial letter of M Jasani
Date: Tue, 16 Feb 2010 09:55:42 +0530


FOR KIND ATTEN: DR. UTPAL RAY, MS. PRIYANKA KAPOOR, MS. DEBJANI RAY

for your kind information and necessary action. AS THE POLICY DETAILS PRIOR TO FEB 2008 ARE NOT KNOWN , THIS CASHLESS REQUEST CANNOT BE ACCORDED.

I have already submitted my receipt of cataract operation and operation details to Ms. Sharmila of your Mumbai Office but I get the same reply. It is not my fault. Your people Mr. Sanjay of Mumbai as well as Mr. Rajesh Kunthe adviced me to your first pay to the hospital and claim afterwards. Please reply me immediately.

I have tried to contact your help line as well as [protected] but not succeed.

My phone no. is [protected].

If i dont get reply I have no alternative to go to COURT OF LAW or CONSUMER COURT.

Thanx

Yours faithfully,

JASANI MAHENDRAKUMAR


From: [protected]@hotmail.com
To: [protected]@medicaretpa.co.in; [protected]@medicaretpa.co.in; [protected]@hotmail.com
Subject: FW: denial letter of M Jasani
Date: Fri, 12 Feb 2010 09:07:18 +0530



From: [protected]@hotmail.com
To: [protected]@medicaretpa.co.in; [protected]@hotmail.com
Subject: RE: denial letter of M Jasani
Date: Fri, 12 Feb 2010 06:26:42 +0530

I submit herewith following in support of my CASHLESS claim for your ready reference. I have also submitted (in person) to Ms. Sharmila Mam and she forward the same. How you say the previous cataract claim details are not known, hence this cashless request cannot be accorded. I, therefore request you again to consider my case favourable and sanction cashless request and oblige.

Thanking you,

Yours faithfully,

Mahendra Jasani



Cataract Surgery Complications
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By Chris A. Knobbe, MD

On this page
Posterior capsule opacity (PCO)
Treating PCO
YAG laser capsulotomy risks
Dislocated intraocular lenses
Other cataract surgery complications
Vision after cataract surgery

Cataract surgery complications are few, but one of the most common is posterior capsule opacity (PCO), which you may have if your vision is cloudy or blurry after cataract surgery. A PCO is a hazy membrane (capsule) just behind the artificial intraocular lens (IOL) that was implanted during your cataract surgery to replace your eye's natural lens.
Although some people call this condition a "secondary cataract," it is not really a cataract. Once a cataract is removed, it does not come back.
Other cataract surgery complications can include eye inflammation, infections or a dislocated intraocular lens.

Why Is Posterior Capsule Opacity a Common Cataract Surgery Complication?
During cataract surgery, your surgeon will remove the cloudy natural lens of your eye (cataract), replacing it with an intraocular lens implant.
When the cataract is removed, your surgeon makes every attempt to maintain the integrity of the capsule that contained the natural lens so the new lens can be placed within it. Normally your vision after cataract surgery should be very clear.
However, about 20 percent of patients with intact posterior capsules have haziness of the capsule, so vision is blurry.
This occurs because lens epithelial cells remaining after cataract surgery have grown on the capsule. In some cases, if the condition progresses significantly, your vision may be worse than it was before cataract surgery.



From: [protected]@medicaretpa.co.in
To: [protected]@hotmail.com
Subject: denial letter of M Jasani
Date: Thu, 11 Feb 2010 10:11:26 +0530

Dear Sir ,

Plz find attached denial letter of Mahendra Jasani.

Thanks ,
Sharmila

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