Shalby Hospitals — grievance: incompetent initial consultation and harassment

Address:	S G Highway, Opp Karnavati Club, Ahmedabad, Gujarat, 380015
Website:	www.shalby.org

My name is ashish. My mother was admitted for knee replacement surgery on 23rd june for both the limbs under single package which stands at 5 lacs. My mom is insured by a mediclaim policy by star health and allied which started in mar, 2017. She was later diagnosed with ild in jul, 2017.
Before admitting, i got initial consultation from dr. Ajit gohel at shalby. During the this consultation, i'd shown all the medication that my mother used to be taking - one of them is for ild by dr harjit dumra of sparsh.
Somehow, the doctor did not give importance to the ild or any other treatment that was underway. He was just focused on knee replacement (As that is their primary goal to meet the numbers i suppose!!)

Basis the initial consultation and x-ray reports of knees, we got the initial approval of 2.5 lac which is 50% of the total sum insured (5 lac) from star health and allied.
Now, during the preoperatives, which happens on the first day when you get admitted, the anesthetist looked at the ild treatment papers and one day later he asked me to put that paper into the shalby file. And, so i did.
Now, star health and allied medial officer took a look at this ild paper. They rejected my claim on the grounds of non-disclosure of ild. Right now, i am having to dole out entire surgery sum which stands at 5 lac. I am not mentally as well as financially ready to pay such large sum of money. I've already paid 3lac and issued a post dated check of 60k which is due in 4 days.

I have the following questions:
1) why initial consultation paper did not have any mention of ild if it is important for the surgery. Had ild been mentioned in the first paper, i would not have got pre-authorization of 2.5 lac and so i would have gone for economy package at krishna shalby or somewhere else for cheaper treatment which i can afford.
2) if initial consultation really did not require it because ild is not related for this type of surgery, then why it was put later on in shalby file causing this entire issue and distress and burden on me.
3) since ild was diagnosed after the commencement of the policy, i want to fight for my rights with star health and allied insurance. But, hospital is not ready to give me the treatment file and so, i am being denied of my rights. Hospital people say that unless i pay the full amount, the file will not be handed over to me. That's harrassment. When i took discharge on saturday, 29th june, i was given assurance by mr. Ravi prajapati that i'll be given the file provided i pay 3lac and issue a check of 60, 000/ post dated. I already paid 3 lacs and my 60, 000/- check is due to be cached on 9th jul. Even after being given the assurances, hospital has now turned back from their words. I've visited the places at least 3 times and every time i met different people as asked. But, the same answer. Do you guys have some single authority who can handle the matter. It's all those without any authority people are handling the matter.
4) why at the time of discharge, mr ravi did not talk to authority and approved. He just faked it as he wanted the room to be vacant, it seems.
5) i have no grudges with regards to the treatment or the staff. They were excellent. It's just that you cannot handle dispute resolution. Plus, the docotors who provide initial consulting do not seem to be trained enough for the ramifications of their consuting papers. People like us are having to bear the brunt of their incompetence. This is not acceptable.
6) why can't the initial consultation be rock-solid to avoid such surprises later on which are distressing for patients and their family?

I was disappointed with shalby, being such a huge name, they do not seem to have any processes - to resolve disputes or for initial consultation. How on earth a layman would think that he would not get anything after pre-authorization of 2.5 lac.

I really look forward to cooperation by hospital so i can fight for my rights with the insurance company.

Thanks-
Ashish