National Insurance Co. Ltd. and TPA is Vipul MedCorp TPA Pvt. Ltd. – Complaint against Rejected Hospitalized Mediclaim by TPA

Vipul MedCorp TPA Pvt. Ltd. – Rejected Hospitalized Mediclaim Sir, My self Neeraj Rathi, working in a private Company i.e. M/s Vayam Technologies Limited, and I have corporate mediclaim policy no. 354900/46/12/8500000194 from National Insurance Co. Ltd. and whose TPA is Vipul MedCorp TPA Pvt. Ltd.. Employee’s individual limit of sum Rs. 1, 00, 000/- with the ratio of 80:20 amount reimbursement, and policy validity from 27/06/2012 and now it is again renew with validity from 27/06/2013. My son Virat Rathi is two and half years old and having hearing problem in both the ears whose card no. is 0210010038775810. We had consulted with Dr. Amit Kishore ENT head of Indraprastha Apollo Hospital, New Delhi and diagnosed deafness in both ears after BERA and ASSR tests. He suggested us for cochlear implant option but before this surgery he advice us to do TTEABR surgery of Virat Rathi to know the result after cochlear implantation. We had hospitalized to my son Virat Rathi on dated 14/06/2013 at 8:18 A.M. in Nova Hospital, Kailash colony, new delhi for TTEABR Surgery and the surgery has been done by dr. Amit Kishore on that day and Dr. Amit Kishore told us that auditory nerve is not present in the brain so, cochlear implant will not be successful at any stage and In this treatment, Nova hospital has charged us as a package of Rs. 40, 000/- and discharged to my son after surgery from the hospital with one day stay on dated 15/06/2013 at 12:07 P.M. I had sent scan copy of all the documents (doctor’s prescription, discharge summary and Nova Hospitals expense bills) to Mr. Abhishek Singh from Vipul MedCorp TPA Pvt. Ltd. who is looking our company mediclaim processes by email on dated 25/06/2013 at 11:57 A.M. with a request to tell us the claim process. But he has not replied us on this. After that I had discussed in our HR dept. for claim process. Then, I had processed and submitted my claim of Rs. 40, 000/- with all supporting original documents. On dated September 12, 2013 5:10 PM, I got a query against my claim process from TPA. Query is as follows: AS PER THE POLICY CONDITION INTIMATION OF HOSPITALISATION IS TO BE DONE WITHIN 7 DAYS OF ADMISSION AND ALL THE CLAIM DOCUMENTS ARE TO BE SUBMITTED WITHIN 30 DAYS FROM THE DATE OF DISCHARGE.BUT YOU HAVE SUBMITTED THE SAME 45 DAYS AFTER DISCHARGE AND HOSPITALISATION INTIMATION HAS NOT BEEN DONE .IN LIGHT OF THE SAID CONDITIONS, WE SEEK YOUR COMMENTS ON WHY YOUR CLAIM SHOULD BE ENTERTAINED? *PLEASE PROVIDE A PROPER FINAL BILL WITH DETAIL BREAKUP IN TERM OF ROOM RENT CHARGES, DOCTORS CHARGES, PROCEDURE CHARGES ETC ( AS YOU HAVE PROVIDED ONLY RECEIPT I had submitted the replied against above mention query with all supporting document to Vipul MedCorp TPA Pvt. Ltd. on dated 18/09/2013 at 10:22 A.M.  Now, they have rejected my claim with the given reason “PATIENT WAS ADMITTED IN HOSPITAL WITH SUFFERING FROM BILATERAL DEAFNESS FOR INVESTIGATION & EVALUATION PURPOSE. HENCE IN OUR OPINION THE CLAIM MERITS REPUDIATION AS PER CLAUSE 4.10 OF THE MEDICLAIM POLICY.THE COPY OF DISCHARGE SUMMARY AND RELEVANT DOCUMENT  ARE ENCLOSED HEREWITH FOR YOUR APPROPRIATE ACTION”. I have paid all hospitalized expenses with a lot of mentally stress. Hence, you are requested to please look into the matter and help me to reimburse my hospitalized expenses from TPA i.e. Vipul MedCorp TPA Pvt. Ltd. Thanks & Regards, Neeraj Rathi | Mobile No.: 9810210311 Address: 4/18, S-2, Abhi Apartment, Sector-5, Rajendra Nagar, Sahibabad, Ghaziabad-201005, U.P., India

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