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Thread: Medi Assist India Pvt.Ltd.

  1. #1
    admin is offline Administrator
    Join Date
    Sep 2008
    Posts
    3,015

    Default Medi Assist India Pvt.Ltd.

    Consumer Complaint No. : PDF/79/2008
    Date of filing : 28/March/2008
    Date of decision : 30/March/2009


    Smt. Vidya Shrimal Khinvsara, )
    R/at : 590, Rasta Peth, Trimurti Towers, )
    Block No. B/2/12, )
    PUNE – 411 002.COMPLAINANT

    : Versus :

    1. Medi Assist India Pvt.Ltd., (Head Office),)
    Third Floor, No.49, First Main Road, )
    Sarakki Industrial Layout, J.P. Nagar, )
    Third Stage, Bangalore – 560 07. )
    )
    2. Medi Asst. India Pvt. Ltd. (Branch Office,)
    Medi Assit, 301, Mantri Terrace, )
    Thube Park, Behind Sancheti Hospital, )
    Shivajinagar, )
    PUNE – 411 005. )... OPPOSITE PARTIES

    *-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-
    Per :- Mr. Gaikwad, President Place : PUNE


    // JUDGMENT //

    This is a complaint alleging deficiency in service on the part of the Opposite Parties. The facts in brief are as under :-

    [2] The Complainant is a house-wife. She had taken the insurance policy from the Opposite Party No.2, which is a Branch office of the Opposite Party No.1 Company situated at Bangalore. The policy was during the period 13/9/2007 to 12/9/2008. The Complainant was required to be hospitalized for the purpose of an operation. She had spent an amount of Rs. 13,460/- towards the medical bills and the operation charges. She had filed the claim before the Opposite Party No.2. The same was however repudiated by the Opposite Party No.2 on 12/11/2007. The Complainant therefore prays that the repudiation of the claim is illegal and therefore there is a deficiency in service. She has claimed an amount of Rs.13,460/- towards her hospitalization and medical charges. She has also claimed certain amount of compensation towards mental agony and torture and for litigating expenses.

    [3] The postal acknowledgments bearing signatures of the employees of the Opposite Parties No. 1 and 2 have been duly received by this Forum. The Opposite Parties were called upon to appear before the Forum on 21/5/2008. On that day, the Opposite Parties failed to appear. The case was adjourned for passing the ex-parte orders, these orders came to be passed on 7/7/2008. The Complainant was directed to verify the documents and to file affidavit in support of the claim.

    [4] The Complainant has filed written notes of arguments on her own. We have perused the same. We have also gone through the letter of repudiation dtd.12/11/2007. It inter-alia reads that the claim was repudiated because incisonal hernia is complication of LSCS, which is done previously before inception of policy, as per IPD papers. As such, the claim is repudiated under Clause 4.1 of the policy contending inter-alia that the said disease was pre-existing at the inception of the policy.

    [5] This is a solitary ground on the basis of which the claim is repudiated by the Opposite Parties. It is clear that the Opposite Parties are duly served with the notice. They had allowed the complaint to proceed ex-parte against them. Alongwith written notes of arguments, the Complainant has filed certain documents in original. Amongst other, two original policy taken by the Complainant for the period 13/9/2006 to 12/9/2007 and for the period 13/9/2007 to 12/9/2008 are produced. The payments of the premium for these two policies had been made on 7/9/2006 and on 12/9/2007. The Complainant was complaining of certain pain in her abdomen. On the advice of her doctor, she underwent ultra-sonography test. The report of that test dtd. 4/8/2007 is produced. The impression mentioned in that report is small reducible incisional hernia. Prima-facie, the disease was disclosed to the Complainant, only on undergoing the sonography test. The same was done on 4/8/2007. This is a period when the Complainant was under the cover. Now on the advice of the medical practitioner, she has undergone the operation on 13/8/2007. The amount of Rs.13,460/- was spent by the Complainant at the time of this operation and during the post operation treatment. It may be mentioned that during all this relevant period, the cover was available.

    [6] Unfortunately, the Complainant has relied upon the next policy commencing from 13/9/2007 to 12/9/2008. The operation was performed on 13/8/2007. It was prior to the inception of the policy. Consequently, therefore, in the previous policy, it was expected on the part of the Complainant to prefer the claim. In any case, we do not find that there is any legal impediment on account of the claim being made for the subsequent policy starting from 13/9/2007 to 12/9/2008. At the time of the operation dtd.13/8/2007, the cover was available during the previous policy from 13/9/2006 to 12/9/2007.

    [7] The other significant circumstance is about the knowledge of alleged pre-existing disease by the Complainant. The repudiation is made solitary on the ground that when LSCS was performed and when the IPD papers were seen, it was disclosed by the Opposite Parties that the said disease was pre-existing. There is nothing adduced by the Opposite Parties to substantiate the same. On the other hand, they had allowed the complaint to proceed ex-parte. Secondly, the Complainant appears to have disclosed all the facts by producing on the record the original documents. If regard being had that sonography was done on 4/8/2007 and the operation was performed on 13/8/2007, it cannot be accepted that the Complainant knew or had reason to believe that she was suffering from incisional hernia. We are therefore inclined to hold that repudiation of the claim is bad in law. The Complainant therefore has satisfied the Forum that there is deficiency in service on the part of the Opposite Parties. She is entitled to recover an amount of Rs.13,460/- from the Opposite Parties. We therefore proceed to pass the following order :-

    // ORDER //

    The complaint is allowed in part.

    The Complainant do recover an amount of Rs.13,460/- together with future interest @9% p.a. from 12/11/2007 till realization thereof by the Complainant from the Opposite Parties No.1 and 2. The aforesaid amount be paid to the Complainant within a period of two months from the date of receipt of this order by the Opposite Parties.

    Other claims are rejected.

    (Smt. S.G. Joshi) (P.K. Gaikwad)
    Member President
    Regards,
    Admin,

    ** PMs asking me for support will be deleted unless I've asked you to PM me with additional details **

  2. #2
    cspundlik@gmail.com Guest

    Smile Lokmanya Hospital Chinchwad Pune-33. Payments held by Mediassist

    There is no response from your Pune as well as Bangalore office to any of our communications


    The letter of 19-04-2010 sent to your Bangalore office still remains pending for reply.


    April 19, 2010

    To,



    Hospital Network Administrator,

    Medi- Assist India TPA Pvt. Ltd.

    # 49, IIIrd Floor, “ Shilpa Vidya”, J.P. Nagar 3rd Stage,

    Sarakki Industrial Layout,

    Bangalore-560078





    Subject: Outstanding Bills of Lokmanya Hospital Chinchwad, PUNE.





    Dear Sir,

    This is to inform you that we have not received the payments towards the outstanding bills mentioned in the enclosed list. We have been informed by your Pune office that the payment – cheques have been held towards the TDS against payments made to Lokmanya CARE Hospital.

    We would like to bring to your kind notice that Quality CARE India Limited, Hyderabad was managing the operations of this hospital under the name of Lokmanya CARE Hospital for the period from 1-04-2007 to 30-11-2009. The payment towards all the cases treated during this period was collected by Lokmanya CARE Hospital (A Unit of Quality CARE India Limited, Hyderabad). Hence the Tax liability lies with Lokmanya CARE Hospital (A Unit of Quality CARE India Limited, Hyderabad) and not with Lokmanya Hospital Chinchwad, Pune,

    Lokmanya Hospital Chinchwad is a unit of Lokmanya Medical Foundation which has taken over the operations from Quality CARE India Limited w.e.f.1-12-2009. The tax liability for the payments towards the bills generaed after 30-11-2009 lies with Lokmanya Hospital, Chinchwad. The intimation about restoration of activities of Lokmanya Hospital, Chinchwad was given to your Pune office on 19-01-2010.

    The payments held by Medi-Assist are towards the bills raised by Lokmanya Hospital Chinchwad (after 30-11-2009) and not by Lokmanya CARE Hospital.

    We request you to kindly look in to the matter and release the payments at the earliest.

    Thanking you,

    Yours truly,





    C.S.Pundlik,

    GM-Business Development.





    Encl: Details of Outstanding Bills.



    CC- Medi-Assist, Pune.



    MEDI ASSIST -Status as on 16 April 2010
    Bill Date Name of Patient Amount ID No Pre. Auth No Status
    1 23/03/10 MRS. LEELAWATI SAWANT 23,513 4005597243 PRE NO.:4820747 & 4843884 REC TDS Rs. 4488.00 Deducted
    2 14/01/10 AMOL ANDHARE 36,703 5001542735 PRE NO. 1585730 & 1588174 Held Against TDS of CARE
    3 09/02/2010 YASODH SREEKALA 10,000 5001072770 PRE NO.: 1603171 Held Against TDS of CARE
    4 22/02/2010 EKNATH BADGUJAR 40,700 5001747271 PRE NO.:4732606 &4766154 Held Against TDS of CARE
    5 03/03/2010 S.K. BIRADAR 15,524 4008980755 PRE NO.:4784303 REC
    6 05/03/2010 PRATIBHA TANDALE 4,392 4009326118 PRE NO.:4787398 REC
    7 10/03/2010 MRS. LUCY DIAS 5,638 4008143886 PRE NO.: 4798785 REC
    8 30/03/10 MR. KHATAVKAR PRAMOD 26,342 4000763030 PRE NO.:4875474 BALANCE
    9 28/03/10 MR. SHASHIKANT MANE 16,564 1375851691 PRE NO.:4865064 BALANCE
    10 25/02/10 LEELAWATI SAWANT 19,009 4005597243 PRE NO 4765908 Held Against TDS of CARE
    11 11/02/2010 PRABHAKAR KARANDE 5,326 4001066710 PRE NO 4717770 Held Against TDS of CARE
    12 18/02/10 ARCHANA GHORPADE 5,000 4008520865 PRE NO 4752503 Held Against TDS of CARE
    13 19/02/10 SUCHETA THORAT 46,380 4009040114 PRE NO 4751637 Held Against TDS of CARE
    14 18/02/10 RAVINDRA KHANVILKAR 10,000 4004489415 PRE NO 4742854 &4754914 Held Against TDS of CARE
    15 15/02/10 GUNESHWAR KAWALE 29,261 4007331064 PRE NO 4733056 & 4738967 Held Against TDS of CARE
    16 14/02/10 DINKAR HOLMUKHE 29,455 4005353994 PRE NO 4716892 & 4735409 Held Against TDS of CARE
    TOTAL 323,807

  3. #3
    Sanjeeve786 Guest

    Exclamation 6 Claim Denial by Medi Assist India TPA PVt ltd but Pre-Existing Diease Cover.

    My First Year Policy No 28251036405 Silver Plan Dt 05/12/2008-04/12/2009, Second Year Policy Number 9202792825015952 Silver Plan Dt 05/12/2009-04/12/2010, Third year Policy Number 9202502825001228 Period 11/12/2010-10/12/2011 Healthwise family Floater Plan (Silver)
    Reliance General Healthwise Policy With Silver Plan Pre-exiting Cover After 2 Year Renews.conntiue renew policy with Reliance General Insurance Compnay .Claim Number Denial By TPA (Medi Assist India TPA Pvt Ltd) Details as under
    1) 6127816 Amt 32061 Rs. (2) 6056039 Amt 10131 Rs. (3) 6087712 Amt 15750 Rs. (4)6006794 Amt 14386 Rs. (5)6128009 Amt 19379 Rs. (6)6171759 Amt 62708 Rs.

    Request you please help me for statlement it claim as soon As possible.

    Many Time contact with TPA & Insuarnce compnay but nothing has been done.
    Insuarnce company give different Serivce request no details as under 2107892, 2090925, 2107892,2073359,2082904,2099240,2107892 etc.

    Regard
    Sanjeev Kumar Saini
    9818994452
    sanjeev79_saini@yahoo.com
    Medi Assist Id Number 4008050120.
    Patient Name Suman Saini

  4. #4
    sudhakar.bhagade Guest

    Post ma id 4001077296

    let me know the my wife had registerd in this medicalm policy

  5. #5
    manohbha is offline Junior Member
    Join Date
    Dec 2011
    Posts
    1

    Thumbs down Mediassist TPA triying to cheat me

    Hi All ,

    My wife was admitted in a nursig home on 14th Nov for delivery and she deliverd my twin babies , i took her home and she was well , on 18th she had a intestinal pain i took her back to the same nursing home thinking it was a problem related to delivery, then we found out that it was a problem in her intestine which was caused due some ulcer , and there a 1 cm hole in her small intestine , then she was operated in 18th and the operation was not sucessful , then i admitted her in Fortis Malar in chennai and the Dr. made another surgery on 26th of Nov and she was supposed to be disharged yesterday but when i went to mediassist for claim they say that this is a continuity of pregenency and they will give me only 75,000 as the claim but the total expence for the surgery is 3.2 L . The Dr. who did the surgery clearly said that this is a prefration that can happen to any one and he is ready to explain this to mediassist . he also said if they can send their Dr's to malar he will provide evidence for the same and also said that he will give his Phone number so that if some one from Mediassist cals him he will be able to expain things to them.
    But no one from Mediassist called him.I took the Discharge summary to a another Gastro surgen and he also said that this is not a problem because of delivery and also said anyone who reads the report will be able to understand the same .Adding on he said may be they are analyising the case with general DRs who are just triying to cheat you - TCS should think about having mediassit as their insurance company.

    I have already spent 70 thousand for delivery and 75 thousand for the previous operation . I do not know how i am going to dischage my wife from the hospital i take her back to my new born babies they have not seen their mother since they were born and are not getting feed from her .My problem should not happen to any one.


    Bharath Kumar
    TCS- Sirucheri
    9884711877

    Last edited by manohbha; 12-08-2011 at 07:11 AM.

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