[Resolved]  Oriental Health Insurance — Cashless rejected without any reason

Address:

Pune, Maharashtra

Hello,

I was about to go through a laproscopy for endometriosis. The reason of the surgery was chronic pain in lower abdomen during menstrual cycles.
Earlier I was taking ayurvedic and homeopathy treatment as pain killers like meftal, meftal spas etc were in-effective for me.
In month of Feb-March 2010, I visited gynecologist in Deenanath Mangeshkar hospital and she advised me to go through laproscopy. For some personal reasons, I started the treatment with some other gynecologist from same department.
During month of June 2010, the endometriotic ceast size grew to 6 cm and it was urgent to do the surgery.
So I applied for my company's insurance submitting all the required papers for cashless facility.
On the day when my surgery was going on, company/TPA sent rejection letter.
They gave the reason that they do not see any reason for admission.
I was admitted to hospital for 2 days and had 4 stitches. My surgery lasted for 2.5 hours and still the company says that there no reason for admission to the hospital.
Are there any doctors working in TPA? Do they really know anything about medical field?
We had to manage the money and pay the hospital bills of rs. 56000/-

I had similar incidence for my father's treatment as well. He had hardaz disease, which affects your vision completely. By God's grace, it was detected in earlier stage and he started with the treatment and recovering from it now.
He had to go through some expensive investigations and later on treatment costing around Rs.8000/-
He is retired from the service so Rs.8000/- is also a good enough amount for him.
He is also covered under my health insurance. So I claimed his medical expenses to same Oriental health insurance.
After 2 weeks, they rejected the claim saying "we cannot see any treatment given under admission. It looks to be mainly for investigation. All the medication is given after admission, which can be taken at home."
I talked to my office agent and resubmitted the claim. But it got rejected again.

If in case of emergency, the insurance company is going to take us down then what is the use of paying so much premium every year?
We take help of medical insurance so our tension during hospitalization is only our dear and near one's health and not money. But looks like these companies just find their way for not giving money, even though we pay premium regularly.