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[Resolved] Medi Assist India Pvt Ltd. - Medical Insurance Claim Denied

Dear Sir, I have corporate Mediclaim Policy under MEDICARE TPA Srevices. Policy No. 920000/34/16/04/00000001 Kamla DEVI MAID: 4010911816 Claim Number H0612160172605F001 (93380447) Initially, I went for cashless treatment, and it got a query was which was answered by Doctor/Hospital and by late evening it was approved. But Hospital had already given the discharge summary, and if I had stayed for more they would have charged again and a new discharge summary was to be issued(as per hospital billing). So, I paid the bill and applied for later reimbursement. First they asked a query - Why the patient was admitted as the treatment could have been done on OPD basis. Doctor/Hospital answered that as the patient had severe anemia and required blood transfusion immediately so need to be admitted. But, now after one month of applying for reimbursement, I get the email that the claim has been denied. Reason for denial: On scrutiny of claim documents, it is found that patient Kamla Devi received conservative treatment (Blood transfusion) for the condition of severe anemia, RA and osteoporosis, patient was admitted primarily for anemia, confirmed in query reply provided by hospital. As anaemia is not payable as per current policy terms and conditions, claim stands denied. We regret our inability to process the claim.Since the claim does not fall within the purview of the Policy terms & conditions, we regret our inability to admit the claim. If you have any other information or documents to substantiate admissibility of the claim, please provide the same within 15 days of receipt of this email/letter. When it was approved while cashless, how come the same can be problematic later, as the treatment was same. While the patient was admitted they even visited hospital to check and gave a "get well soon card", and now at the end claim denied, In-spite of paying for this medical insurance for many many years for four people, this is what one get when the need arises. What a shameless act of deceiving people. Thanks Sudhir 9599349880

1 Dec 25, 2016 08:29 PM Business and Finances


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The issue has been resolved completely.

Feb 23, 2017 01:51 PM