Mr. S L Narula, the complainant has stated in his complaint that a mediclaim for treatment of his son had not been settled by the insurance company till date. The complainant stated that his son met with an accident on 24.09.2017 and was admitted in the ICU of Kailash Hospital on the same day. The complainant had found a health card (corporate policy purchased by the employer of his son) in the wallet of his son and the same was handed over to the hospital for availing cashless treatment. M/s Med save, the TPA in this case, sanctioned cashless treatment up to Rs. One lakh as sum insured under the policy was Rs. One lakh only.
When the expenses of treatment exceeded the limit of one lakh, the hospital asked the complainant to pay the balance amount. At that time, when he again searched documents of his son, he came to know that his son had also purchased another policy (Individual Mediclaim Policy) with a sum insured of Rs. 3 lakhs from the same insurer. Accordingly, he handed over the health card of the second policy to the hospital. In order to avail cashless benefit under second policy, the hospital discharged the patient on 29.09.2017 at about 7 PM and re-admitted him on the same day after two hours.
This exercise was done only in records as the patient remained admitted in the ICU during the intervening period of two hours. The Claim papers for Rs. 2, 06,188/- were submitted to the TPA who sanctioned Rs. One lakh only and disallowed balance amount of Rs. 1, 06,188/- in view of sum insured under the policy. Later, another claim of Rs. 94,800 for the hospitalization period from 29.09.2017 to 03.10.2017 was submitted to E-meditek, the TPA of second policy which was approved and paid by them. Since, the insurer was same in both the policies, the complainant approached the insurer several times requesting them to settle the claim for unpaid amount of Rs.1, 06,188/- under the second policy but failed to get any relief.
The insurer stated that the TPA of the second policy had advised the complainant to submit original /certified documents for hospitalization which were submitted by him to M/s Med save, the TPA of corporate policy, so as to enable them to process reimbursement of balance amount of Rs. 1,06,188/- but the complainant failed to submit the same, hence his claim could not be settled by the TPA of the second policy (Individual Mediclaim Policy).
The complainant stated that he was unable to understand as to why his claim had not been settled till date, when both the policies were issued by the same insurer. The insurer admitted that due to lack of coordination between the two TPAs, the claim for balance amount could not be settled. However, the insurer assured that the claim would be settled within one week from the date of receipt of required documents.
