Reference Policy Nbr : 253900/48/2010/4469
Claim Nbr : 15831617

My family and me have been mentally harassed by the events that happened through out the last week due to sheer negligence and unwanted delay in approving the claim (Ref : 15831617) for the policy holder, Atul Kumar Goyal.
We went for a laparoscopic surgery of disease Hernia at Metro Hospital, Sec 11, Noida.
The admission at the hospital was done after sending a Pre Auth of Rs 48,100 (Package for Surgery including cost of Protec + Mesh) to the TPA on 16th of December 2010.
The TPA after asking for a copy of last 5 years policy copies which we provided on the request granted an initial approval of Rs 24000 on the same date. At the first place, they didnt raise any flag or any sort of objection to the sent Pre Auth amount which in a way made the hospital and us believe that everything is going well.

But to everyone's surprise, after the surgery, only an amount of Rs 3200 (approx) was approved as the final settlement. The note with the approval said that the approval has been done in accordance with the GIPSA agreement.
The patient was to leave the hospital on 23rd of December.
We were bemused with such a surprise and then a series of discussions/arguments followed that compelled us and the patient to stay in the hospital for 23rd full day and then night and then subsequent full day i.e. on 24th till late night.
The TPA representatives (so many of them), mainly , Mr Ashutosh was very firm with this decision and according to him, the hospital was at fault for charging high.
We had a series of long calls between the TPA and the hospital involving us and a never ending argument finally made us believe that it was hospitals fault only.
The police was called in the hospital on 24th night and we asked for a let off (patient leave) on the basis of proper security deposited with the hospital.
After another next day long fight on 25th, it was finally the next day only when another approval (complete approval) of Rs 47200 (approx.) was approved by the TPA.

Throughout the argument, Mr Ashutosh, was laying baseless allegations on the hospital also, which made us to believe if they really are at fault.
We have faced serious trauma and my parents were in serious shock throughout the lapse of this long spell of indecision and delay which caused unnecessary tension among us.
We are not NCR localites and hence, also incurred heavy expenses for our unwanted extended stay of 2 days at hospital (patient with family attendants inside and outside the hospital).

I, myself, working in a private multinational company know how swiftly the approvals are granted for Corporate policies. I know the Terms and conditions are different but this was an Individual policy with a no claim since last continuous 5 years and there is no condition different which could suggest a case of part approval for a Hernia surgery.

We are seriously mentally hurt by this incident and we need a proper answer along with necessary compensation for our sufferings. Also, the necessary action, be needed, against the TPA representative who is not bothered and not willing to cooperate even now after the incident.
There has been enough stick beating the bushes in this episode and we won't tolerate any more twists and tales around the story and will not close the matter just for the sake of it.


Looking for cooperation at least now,

Note : Email copied to Oriental Insurance Grievances Dept, IRDA, copy faxed to NCDRC