This is to bring to your kind notice that my spouse had got a surgery done in the month of June’2012 and still awaiting my medical claim to get settled.
I am working with Indus Ind Bank and our have corporate tie up is with Iffco Tokio for medical insurance and since Iffco Tokio does not deal directly with its corporate clients, PARAMOUNT (TPA) has been given the responsibility to assist clients/employees.
Before I present the complete case, I would like to brief you about my spouse’s medical history:
1. We have been married for 8 years and have not been blessed with baby so far. Have been treated by many gynaecologists but since reports were normal, we had left the things long back considering that certain things are in the hands of GOD.
2. My spouse was suffering from acute abdominal pain since December 2011 and preliminary started with Ayurvedic Treatment.
3. When Ayurvedic treatment did not help her in getting any relief, she switched over to Homeopathic Treatment .Considering that though Homeopathic Treatment is effective but bit slow in curing the problem, we consulted Allopathic Doctor too.
4. Both the Doctors termed the problem as Menorrhagia and Dismenorrea and were advised to go for Laparoscopy by Allopathic Doctor-Dr. Poonam Khera as the problem was getting worst day by day.
5. She decided to undergo Laparoscopic surgery and got herself admitted to Hospital B.L Kapur, Rajender Place, Delhi on 23.06.2012. I completed all preliminary formalities regarding hospitalization on 22.06.2012 and forwarded all relevant documents to Paramount for cashless claim. I was assured by Paramount Representative that our hospital bills will be paid by insurance company and the approval is expected to come in a day.
6. On 23.06.2012, my spouse inquired about the status of claim from Hospital’s representative at TPA help desk who in turn called Paramount and was told that the claim has been rejected and the clear reason of rejection was Treatment(Laparoscopy ) taken for Infertility.
7. We tried to convince Paramount representative that treatment taken is not for infertility and the problem is to diagnose the reason of acute pain in abdomen but all in vain and in very casual way were advised by Paramount Representative to forward all documents for reimbursement after getting discharged from hospital.
8. On 24.06.2012, I was discharged from hospital and two days later I started my follow up with Paramount to confirm Reimbursement process to enable us to apply for reimbursement .Again on several follows with Paramount which were quite disturbing, we were provided with Checklist of documents.
9. We again forwarded the required set of documents in original to Paramount on 02.07.2012 and were asked to wait for a fortnight to get the approval. 20 Days after 02.07.2012 and completion of said fortnight, when we did not receive any response from Paramount, I called Paramount representative and was asked to wait for another week’s time.
10. On 02.08.2012, we again tried to call Paramount and finally got through Paramount representative only after rigorous calling .Representative again advised us to be patient for another one week as it was still under process .Since the month of August was full of Public Holidays, we called Paramount on 16.08.2012 giving them sufficient time to process the case.
11. On 17.08.2012, we called Paramount and the answer was same. They again required some time to confirm the status. This made us annoyed and I gave a piece of mind to Paramount Representative. Two days later we were confirmed from another representative of Paramount that the case has been repudiated last month i.e July2012 by paramount and now being forwarded to insurance company IFFCO TOKIO as a special case.
12. In third week of August’2012, we had representative from Iffco Tokio who visited our residence to cross check documents without any prior intimation/call. Upon confirmation of his surprise visit, he confirmed that this is their company’s policy to give surprise visit to client’s place. My spouse welcomed the representative and showed him all documents relevant to my treatment/surgery.
13. Week later I called Iffco Tokio to confirm the status of my case on which we received a mail from Paramount seeking clarification as to how why we had 2 Operation Notes in the discharge file. and would also want us to submit – All relevant consultations pertaining to treatment.
14. We clarified from Doctor Poonam Khera regarding issuance of 2 operation notes from hospital and were confirmed that the first note had a clerical error and was made by resident doctor who erroneously mentioned the treatment as infertility. To avoid further problems, second note was issued mentioning the correct problem of the patient. We also took a note from Doctor on hospital’s letter head confirming that the treatment taken was not for infertility and Laparoscopy has been done to diagnose reason for acute pain in lower abdomen.
Till date we have not received claim from Iffco Tokio.Request your kind intervention in this regard.