[Resolved]  Raksha Tpa — REFUSAL OF CLAIM

Address:

Amritsar, Punjab

My self Manish Baluja s/o Sh.Balbir Chander Baluja,R/o # 76,St. No.1,Kapoor Nagar,Sultan Wind Road,Amritsar,working with M/s Organic India Pvt. Ltd.,Lucknow at Amritsar Head Quarter as Senior Sales Executive.

My Company has provided me a Medi claim Policy of Raksha TPA as per details.

Policy No.: 082401/48/09/87/00000079
Member ID : UIC545264ORGA

Unfortunately, My son Ritish Baluja ,aged 9 years on that time suffered from Retina dislocation in his right eye, which was detected 6 weeks before the surgery.
When we got this investigation report from Doctor, He suggested that my son is in need of Surgery immediately to protect his left eye from extra pressure.
I was having the facility of Cash less treatment from Insurance company as per details given above so I was interested to take the benefit of Policy for Cashless treatment of My son.
Dr. Vipan Kumar Vig (Retina Vitreo Consultant) S.B. Dr. Sohan Singh Eye Hospital, Katra Sher Singh, Chowk Fareed, Amritsar has sented a request through fax to Raksha TPA for Cashless Treatment of My Son on 12.11.09.
In the reply of that request ,Raksha TPA demanded all the Past treatment details of My Son on 12.11.09
Dr. Vipan Kumar Vig, Has submitted the all past history of Treatment with his letter ,in which he wrote by mistake that the Retina Dislocation is CONGENITAL along with the disease of P.H.P.V(Presistant Hyper Plastic Vitreo) & Squint in Right eye.
In the reply of this letter from Raksha TPA, vide their letter no. RAKSHA/[protected] dated 17.11.09 ,in which Raksha refused the request of Cashless Treatment due to the CONGENITAL disease.
Again Dr.Vipan Kumar Vig , sented a Letter through E-Mail on 19.11.09 in which he Certified the disease was not CONGENITAL & it was written there by Mistake. In his letter he also mentioned that, “The child is suffering from “COMBINED TRACTIONAL RHEGMATOGENOUS RETINAL DETACHMENT” in his Right Eye since about 6 weeks .This Condition in not CONGENITAL in nature. The Child is going to be treated for the Retinal Detachment which is fresh in occurrence and not CONGENITAL”
But the response of Insurance Company was shocking, They have not replied the letter of Dr.Vipan Kumar Vig till date. Insurance Company acted most irresponsible ,Unethical & Illegal manner & have not respond after getting the Certification from Doctor till date.
That due to wrongful rejection of Claim of the Expense of Hospitalization, I have suffered a lot & also received great mental agony, harassment and the attitude of Insurance Company seems to be deficient ,negligent and careless one.
I have admitted my son in S.B.Dr.Sohan hospital on 20.11.09 for the surgery of his Right eye & spented 36667/- inspite of having Cashless Medi claim Facility from Insurance Provider Company.
I am submitting my Complaint in this site to get Justice from your end.I have suffered lot & right now I am suffering.
I am lodging my complaint for cash back of treatment Expenses of Rs. 36667/- & Rs.50000/- for the mental Pain ,agony, harassment for illegal acts & irresponsible attitude of Insurance Company along with the interest @18% p.a.
I hope that, In Consumer Complaint Site I will definite get Justice & it will be a great example for Insurance Companies, who cheating Customers.
in wait of your reply.
Manish Baluja S/o Sh.Balbir Chander Baluja,
R/o # 76,Street No. 1,Kapoor Nagar,
Sultan Wind Road,Amritsar,Punjab
Cell : [protected],[protected]
Email : [protected]@gmail.com
Email : manish.[protected]@organicindia.com