• Medicaim rejection

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 8 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 
Ajay Sethi
Advocate, Mumbai
23217 Answers
1219 Consultations
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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.  
Ajay N S
Advocate, Ernakulam
1915 Answers
19 Consultations
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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.
Pradeep Bharathipura
Advocate, Bangalore
4105 Answers
133 Consultations
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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.
Ashish Davessar
Advocate, Jaipur
18102 Answers
448 Consultations
5.0 on 5.0
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.
T Kalaiselvan
Advocate, Vellore
14006 Answers
127 Consultations
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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 

Ajay Sethi
Advocate, Mumbai
23217 Answers
1219 Consultations
5.0 on 5.0
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. 
T Kalaiselvan
Advocate, Vellore
14006 Answers
127 Consultations
5.0 on 5.0
Send both the documents as you have nothing to hide.After claim rejection you can issue a legal notice to them. 
Ashish Davessar
Advocate, Jaipur
18102 Answers
448 Consultations
5.0 on 5.0

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