United India Insurance Company [UIIC] — mediclaim has cheated us

Address:

517, Ittina Soupernika, Kaikondrahalli, Sarjapur Road, 560035

My father Mr. Manabendra Banerjee, age 65 years, was hospitalized at Bhandari Hospital Research Centre (138-A, Vasundhar Colony, Gopalpura Bypass, Tonk Road, Jaipur-302018) on 31st March 2019 for an Arthroscopic Surgery (Arthroscopic Rotator Cuff Repair + Subacromian Decompression Right).

Few points to be noted before we proceed:

· The surgery was done on 1st April 2019 by Dr. Rajeev/Ankur Gupta

· Medical Diagnosis done for the same was – Supraspinatus + Sub Scapularis Tear Right

· H/O Fall from Bike, C/O pain Swelling of right shoulder since last 8 months, A/W Difficulty in movement

· The procedure done on my father’s right shoulder was because of an accident and not because of a body deterioration due to old age

The hospital is enlisted for cashless hospitalization with the insurance provider. With this respect, I state the following:

· On 28th March 2019, an intimation was sent by the hospital for preauthorization for the sum of Rs.2, 27, 000/- (rough estimate), (attached – scanned copy of “Request for Cashless hospitalization for Medical Insurance policy” form)

· On 29th March 2019 the hospital received an intimation of initial amount authorized as Rs.1, 35, 000/-. The terms and condition for authorization was to collect 10% co-pay on final bill. Room rent limit Rs.2, 400/- and nursing charges restricted to Rs.600 per day. The same was conveyed to us via email (attached “email”) from Mediassist (TPA) and also by the hospital over phone

· Once we got the pre-authorization then only we decided to go ahead with hospitalization and the aforesaid surgery

Now, on the day of discharge, i.e. 3rd April 2019, the following events occurred:

· The final bill of Rs.2, 41, 813/- was sent to Mediassist by the above stated hospital for approval (attached scanned copy final bill Dt. 3rd April 2019)

· Ironically, now Mediassist authorized a sum of Rs.75, 000/- only, against an earlier sanction of Rs.1, 35, 000/- (attached scanned copy email Dt. 3rd April 2019 received from Mediassit by the hospital)

· This has brought us to a juncture, where we were left stranded at the hospital for us to pay the remaining huge amount Rs.1, 66, 813/-, without which my father could not be discharged from the hospital. We have settled the bill as we did not want to be branded as a defaulter

To reiterate few of the points from above:

· The initial amount authorized was Rs.1, 35, 000/-

· The final amount authorized is Rs.75, 000/- only, while the final bill amount was Rs.2, 41, 000/-

While I was trying to contact the Mediassit for escalation, none of the phone numbers worked. When finally, I could reach one of the contacts, after a lot of effort, the answer I was given is that, “the pre-approved amount for Arthroscopic surgery is Rs.75, 000/-, we cannot do anything for resolving your situation”.

Incidentally, in spite of my raising ticket, on two occasions, for providing me with this year’s policy document[protected], I was not furnished with the same (mails and ticket details attached). Thus I was not aware of any cap or limitation. This is also deficiency in service to customer.

We take parental insurance so that we could help our parents at old age. My father is a retired man. However, under these circumstances he was compelled to pay such huge amount for which we were totally un-prepared. This amount could have come in use in future for other ailments, or some other domestic requirements.

Please address the following queries:

- If the fixed amount for Arthroscopic Surgery was Rs.75, 000/- then why did a pre-auth amount was advised as Rs.1, 35, 000/- from Mediassist, when every detail was provided by the relative hospital?

- When the authorization came for Rs.1, 35, 000/-, how could you reduce the amount to Rs.75, 000/- in the final bill? On the contrary, the final amount authorized should have been more than Rs.1, 35, 000/-, if not, at least this amount of Rs.1, 35, 000/- should have been authorized as that was already approved

- Even after repeated intimation, why was I not provided with the policy document?

- This is not an ailment due to old age, but an accident what my father has met, unfortunately. How can the both be comparable?

I expect better service from the insurance provider. I am a Wipro employee from the last 10 years. I expect that that I would be given full support from the organization. Arranging money at such a short notice was such a herculean task apart from the mental trauma what we have gone through. If I would have known during the time of pre-authorization only that we would only get Rs.75, 000/-, then we would have done some due diligence and thought other methods of payment. This entire episode has caused lot of harassment and inconvenience to my parents.

I, therefore, request you to re-examine the claim in the light of what has been stated in this communication and reimburse me the balance amount of Rs.60, 000/-.