Family Health Plan (Tpa) Ltd — Rejection of reimbursement claim - Health insurance

Address:	Hyderabad, Andhra Pradesh
Website:	Family Health Plan (TPA) Ltd

Hello, I Lokesh N Shah holding a policy # 355000/46/14/[protected]. I have taken the above Health insurance policy by paying 20K as a premium for sum of 2 lacs. Recently, my father was hospitalized and as Cashless treatment was denied, I had to pay whole hospital bills from my pocket. The, I did furnish all the relevant/ required- discharge summary, diagnostics report, day to day activity report to TPA for reimbursement claim on July 02. On Sept 11, 2015, I received an mail from TPA stating my claim has been denied stating Clause no. 4.10. At the time of taking the insurance, you give us 2 sweet options: - Cashless treatment - Claim reimbursement by submitting the bills/ discharge summary I am paying INR 20K/ per annum from my pocket just to insure my parent’s health. Now, almost after 70+ days, you straight away deny the claim. What does the below mean? As per our medical opinion and submitted documents, the present hospitalization is for the investigation and evaluation of the ailment only. Hence we regret to inform that your claim is repudiated.Clause no. 4.10 Did anyone from your insurance company visited the hospital in person to see the patient as to what for he is been hospitalized and is it only for investigation and evaluation of the ailment? As far as I know, any human being will be taken to hospital once he /she is suffering from some ailment/ disease/ injury and then doctor’s in hospital will do their investigation / evaluation, diagnostics and then advises the further medication. You or your FHPL team cannot expect that patient should again have scissors/ epilepsy in front of doctor’s team. Then you say it fits in your clause and approve the reimbursement.