Hi, I have a eriction tpa health insurance for my wife. Recently she had undergone a fibroid surgery at a hospital in bangalore. She was dignosised of fibroids in utrus causing heavy bleeding and pain. When infomercial the doctor that she has insurance they said we can pay and get the surgery done here later claim the money thru insurance. The 1st visit to the hospital was dated 26th Jan 16 and they gave her some pain killer medicine and asked to do ultrasound. Post ultrasound report it was found that she has 3 fibroids , the bigger on is of 7 cm- 7 cm. The doctor suggested for the surgery and the same was done thru laproscopy on 14th Feb. There was some complication in the 1st sitting hence on 18th March again the same was performed thru open surgery. But due to some error the doctor mentioned in one of the doctor note in the 1St sugery sitting as cause of infertility since we don't have child. When I had to sent the xerox papers to the insurance the same was rejected . Later I went to the hospital and asked how did they mention it as a case of infertility when I have not visited here for some infertility treatment. The hospital acknowledged the error and have me a revised doctor procedure note along with a declaration stating such error has happened and the case was medicated for excessive bleeding and pain. All the original papers are with me but the insurance company is not processing the papers and claim. Need some advise and some good lawer at mumbai who can handle this case.
Asked 7 months ago in Civil Law from Bangalore, Karnataka
1) you will have to move consumer forum against the insurance company fir rejection of your claim
2) seek recovery of amount paid by you to hospital with interest
3) also seek compensation for mental torture undergone by you
The trust upon the claim was lost to the insurance company . Any way you may claim with the new appropriate document. If the company is not proceed your application the only remedy available is approach the consumer forum and claim damages against the hospital also.
Hi, you have to lodge a complaint in the District Consumer forum in Bengaluru against Insurance company for deficiency of services.
2. First you have to issue a legal notice and thereafter you have to file a complaint in the consumer forum.
You can issue a lawyer's notice to insurance company for deficiency in service, and if this does not wake it from its slumber then you can file a case in the Consumer Forum to seek the insurance amount along with compensation for the hardship undergone by you.
This is a fit case for consumer forum.
The insurance company cannot repudiate claim for any silly reason when they have collected the insurance premium for this.
You can take up the matter through consumer redressal forum.
You can seek claim amount besides compensation for the mental agony and stress and loss of physical as well as mental health.
For a good lawyer at Mumbai, you can look for one yourself.
Sirs, Thanks for your replies.
Now the insurance company is asking me for the original documents so that they can issue me a claim rejection letter and after which I can send them a legal notice. Now the hospital has changed the doctors note document where they have wrongly mentioned it as a case of infertility. So can you suggest me should I send the revised correct document or both old ( mentioned as case of infertility ) and revised correct document ( mentioned as a case of heavy bleeding & pain. Also for the earlier mistake the hospital has given me an undertaking clarifying that its a mistake. Whether this hospital declaration document need to be submitted to the insurance company in original in order to obtain the claim rejection letter. thanks for your all your help.
Asked 7 months ago
1) you can submit certified copies of all documents to insurance company
2) if insurance company is asking for original submit all original documents and obtain acknowledgment of receipt by insurance company
You have to sendal the original documents relevant to this insurance claim by retaining a certified photocopy in your possession. You have to enclose them under a covering letter along with the claim form and can make a mention in brief about the description of the enclosed documents as a ready reference.
Let them reject the claim, you can drag them to the consumer forum as per law.
Send both the documents as you have nothing to hide.After claim rejection you can issue a legal notice to them.