The Oriental Insurance Company Limited — reimbursement claim - cheating by tpa and the oriental insurance company limited

Address:

Gurgaon, Haryana, 122002

After much to and fro, i had filed a complaint with ombudsman last may but i still haven't received any response from them. Kindly help

Reference: happy family floater – 2015 policy no.: 215300/48/2017/913 on[protected].

Dear sir,

With reference to the above, please find enclosed the reimbursement claim, along with the duly filled form and all relevant documents.

The claim was initially lodged with your appointed tpa - emeditek tpa services limited through max healthcare gurgaon and all the relevant documents were submitted to them. Subsequently, the tpa issued a pre approval on 10th february 2017 for rs. 50000/-, which was subsequently increased to rs. 70000/- on the same day and a fresh pre approval was issued by emeditek.

The undersigned – insured / patient archna singh, after receiving the pre approval got admitted to max healthcare gurgaon on the 11th of february 2017 and got her surgeries performed and got treated for her ailments.

On 12th february 2017, the undersigned was discharged from the hospital and the relevant discharge summary and the final bills were sent to emeditek by max healthcare for the final approval and for releasing the payment advice. Emeditek after several hours sent a query asking for past medical policies, which after great difficulty were located and sent to emeditek. Thereafter, the tpa took several hours yet again and sent a email rejecting the claim and directing the undersigned to make a reimbursement claim on the oriental insurance company limited directly. The flimsy grounds mentioned by the tpa was that, the surgeries need a minimum of three years of standing, before they can be considered for claims.

With no alternative left, the undersigned had to pay the entire bill of the hospital, amounting to rs, 1, 61, 216.00 using her credit card and got discharged to go home.

Now, there are very pertinent questions which arise,
(1) why did the tpa issue the pre approval without inspecting the previous policies;
(2) the tpa did not consider the clarifications issued by the renowned doctors of max healthcare, which clearly shows that the surgeries performed were well within the purview of consideration by the tpa;
(3) had the surgeries not been within the purview of consideration, the insured / patient would have waited for 4 months, got the third renewal done and then got the surgeries performed. The ailment was not life-threatening and the surgeries could well have been postponed by 4 months and could have been performed later, and the situation was not that one of any emergency.

Why was a pre-approval sanctioned and issued by the insurance company appointed tpa, without verification of all documents? Once a pre-approval is issued, it means that the insurance company is liable to pay the expenses.in case the policy conditions did not approve payment of the claim, the pre-approval should never have been issued and the claim rejected before the insured / patient archna singh got admitted and got the surgeries done. The tpa or the insurance company cannot issue a pre-approval and ask the insured / patient to get admitted and get the surgeries done, and when the final bills are submitted or the payments, reject the claim on the grounds that the policy conditions do not approve of this. It is the duty and responsibility of the tpa and the insurance company to verify all the documents upfront, when the claim forms are submitted and only after being convinced issue the pre-approval. The tpa and the insurance company in this case has done fraud with the insured / patient and cheated her.

The discharge summary and final bills were submitted on[protected] @9.07am to emeditek, and till 9.32pm on[protected], full 12 hours after the final bills were submitted to emeditek, there was no concrete reply from them. The behaviour and actions of the tpa and the insurance company were totally inhuman and the biggest mistake made by them was issuing the pre-approval without verifying all the documents. By keeping a patient in the hospital for 12 hours within 24 hours of her surgery, the tpa and the insurance company has done a dastardly act and this caused much agony, harassment, mental torture and indisposed the insured / patient post surgery, when she should have been resting at home and on the path of recovery.

In light of the absurd, fraudulent and act of cheating done by the insurance company appointed tpa and as per the advice of the tpa, we are forced to file this claim for reimbursement. All documents enclosed are photocopies, however the originals can be produced on demand, for inspection.

You are kindly requested to consider the claim, and have the entire amount reimbursed on top priority.


Thanking you in anticipation.

Sincerely,

Archna singh