Partial denial of claim for Hospitalisation Expenses.

NAME:-SANDEEP BHARDWAJ.
POLICY NO: 1213002816P101912045
CARD NO:- UN-3-74262
UIN NO:- IRDA/NL-HLT/UII/RH/V.I/228/13-14
COMPLAINT NO. WITH BIMA LOKPAL: PUN-051-1718-0421
JUDGEMENT(AWARD) BY BIMA LOKPAL - NO.:IO/PUN/A/GI/0048/2018-2019

THE INSURER HAD PARTIALLY DENIED THE CLAIM AGAINST HOSPITALISATION EXPENSES BECAUSE OF WHICH I HAD COMPLAINED TO BIMA LOKPAL, PUNE.IN IT'S AWARD THE BIMA LOKPAL DIRECTED THE INSURER TO PAY RS.9,591/= BUT I AM NOT FULLY SATISFIED WITH THE JUDGEMENT SO I AM REGISTERING THE COMPLAINT WITH CONSUMER FORUM.

I WROTE TO BIMA LOKPAL,AFTER THE AWARD OF THE JUDGEMENT,TRYING TO CONVINCE THEM TO REVIEW THE AWARD AND DIRECT THE INSURER TO PAY ME ADDITIONAL RS.28,686/- WHICH I THOUGHT IS JUSTIFIED.I HAD ATTACHED SUPPORTING DOCUMENTS ALSO TO PROVE MY CASE BUT THE BIMA LOKPAL DID NOT REPLY TO MY LETTER AND WHEN I TALKED TO THEM ON PHONE I GOT REPLY FROM THE BIMA LOKPAL OFFICE THAT ONCE THE JUDGEMENT IS AWARDED THE CASE GETS CLOSED SO I MAY APPROACH OTHER FORUM FOR JUSTICE. HENCE, I AM APPROACHING CONSUMER FORUM.

THE DISPUTE IS REGARDING HOSPITALISATION CHARGES FOR THE ROOM CATEGORY FOR WHICH I AM ENTITLED TO AS PER THE POLICY WHICH IS RS.1,500/-PER DAY WHEREAS I HAD OPTED FOR RS.5,000/- PER DAY ROOM RENT IN APOLLO HOSPITAL WHERE MY WIFE HAD UNDERGONE TREATMENT.

PRIOR TO THE DAY OF MY HEARING ONE DAY I HAD VISITED THE BIMA LOKPAL OFFICE IN PUNE WHERE I WAS TOLD BY ONE OFFICER NAMED MR.BARDHAN THAT I SHOULD GET THE RATES OF HOSPITTALISATION CHARGES OF OTHER HOSPITALS IN THE VICINITY OF THE HOSPITAL IN WHICH MY WIFE HAD UNDERGONE THE TREATMENT FOR SUPPORTING MY CASE. I COULD NOT SPARE TIME FROM MY BUSY WORK SCHEDULE IN MY JOB SO I COULD NOT DO THE NEEDFUL.
THE BIMA LOKPAL IN HER AWARD OBSERVED THAT HAD I PRODUCED THE HOSPITAL RATES HAVING ROOM RENT OF RS.1,500/-(THE ROOM RENT WHICH ACCORDING TO MY POLICY I AM ENTITLED FOR) AT THE TIME OF HEARING THAT WOULD HAVE HELPED IN DECIDING THE FINAL AMOUNT TO COMPARE WITH THE DEDUCTIONS MADE BY THE RI.
I WAS NOT CONVINCED WITH THIS POINT IN THE AWARD SO INSTEAD OF GOING TO VARIOUS HOSPITALS I WENT TO APOLLO HOSPITAL ITSELF TO FIND OUT THE RATES OF VARIOUS HOSPITAL CHARGES FOR THE LOWEST ROOM RENT CATEGORY IN THE HOSPITAL WHICH IS RS.2,500/=. I COMPARED VARIOUS CHARGES OF APOLLO HOSPITAL FOR RS.2,500/- AND 5,000/-AND ON PRO-RATA BASIS I DERIVED THE CHARGES FOR RS.1,500/- RENT AND EXPLAINED THE SAME IN MY LETTER TO THE BIMA LOKPAL, I AM ATTACHING THAT LETTER HEREBY FOR YOUR PERUSAL.I AM REASONABLY JUSTIFIED BY MY CALCULATION AND I AM CONVINCED THAT I SHOULD BE PAID RS.28,686/- MORE BY THE INSURER.

THE OTHER DISPUTE IS THAT THE INSURER HAD NOT PAID ME CT SCAN CHARGES OF RS.3,750/- SAYING THAT I HAD NOT SUBMITTED ORIGINAL CT SCAN REPORT. ACTUALLY HOSPITAL HAD NOT GIVEN ME THE SAME AT THE TIME OF DISCHARGE, PERHAPS THEY HAD SUBMITTED TO THE TPA AGAINST CASHLESS TREATMENT.
I HAD WRITTEN TO THE TPA ABOUT THIS(SCANNED COPY OF THAT LETTER IS ATTACHED HEREWITH).
SO I WENT TO THE HOSPITAL AND I GOT A TRUE COPY OF THE REPORT DULY STAMPED AND SIGNED BY THE HOSPITAL. I SUBMITTED THE SAME TO DR.KINJAL SHAH OF THE TPA DURING MY HEARING IN PRESENCE OF THE BIMA LOKPAL AND GOT HER SIGNATURE OF ACKNOWLEDGEMENT OF THE RECEIPT IN MY COPY OF THE REPORT WHOSE SCANNED COPY I AM ATTACHING HEREWITH.
LIKEWISE THE INSURER HAS NOT PAID ME RS.3,870/= TOWARDS POST HOSPITALISATION EXPENSES SAYING THAT THERE ARE NO ENTRY OF THE BILLS WITH THE TPA. IN FACT I HAD SUBMITTED ORIGINAL BILLS VIDE MY LETTER DTD.10/7/2018 WHICH I HAVE ATTACHED HEREWITH. DURING MY HEARING I HAD RAISED THIS POINT TO THE BIMA LOKPAL AND HANDED OVER THE PHOTO COPIES OF THESE BILLS AND COVERING LETTER TO DR.KINJAL SHAH OF THE TPA TAKING HER SIGNATURE ,TOWARDS ACKNOWLEDGEMENT OF THE RECEIPT, IN MY COPY OF THE COVERING LETTER WHICH I HAVE ATTACHED HEREBY.
UNFORTUNATELY THERE WAS NO MENTION OF THE DISPUTE FOR RS.3,750/- AND RS.3,870/- IN BIMA LOKPAL'S AWARD.
AND WHEN I APPROACHED THE INSURER'S TPA THEY SAID THAT SINCE IT WAS NOT MENTIONED IN THE AWARD THEY HAVE NOT PAID THESE AMOUNTS.
TO SUM UP- MY CLAIM WITH THE INSURER IS FOR RS.28,686/- +RS.3,750/- + RS.3,870/- TOTAL OF WHICH IS RS.36,306/-

N.B:- I COULD ATTACH ONLY MY REPLY LETTER TO BIMA LOKPAL AND PARTIAL PAGES OF AWARD OF BIMA LOKPAL AS THE SITE IS NOT TAKING MORE ATTACHMENTS. KINDLY ADVISE HOW DO I SEND YOU OTHER SUPPORTING DOCUMENTS FOR MY CLAIM.