Hi,
1. I am Employee of Eclipsys India Pvt Ltd. we have Group Policy of Medical Insurance on hospitalization for at least 24 hours with ICICI LOMBARD,TPA is Paramount Health Sevices.
2. I was taking medication for severe Stomach ache, Headache from almost 3 weeks from Dr. Vinay K. Thorat (MD Gasto), suddenly my condition became critical from almost 4 days i was having vomiting just after taking my food ( Breakfast, Lunch, Dinner ) and severe stomach and Head Ache was there.
3. I visited doctor at his clinic (Krishnai Clinic) and my stomach ache wasd unbearable at that moment, Doctor suggested Me to be admitted in Poona Hospital and Research Center Immediately.
4. I was admitted that evening itself and asked doctors to claim for cashless facility that is valid for availing.
5. Doctors send the letter to Paramount Health Services stating that I have been kept on IV due to emergency reason and being treated and investigated for the problem on date 09-09-09.
6. Paramount Health Services Asked a to provide Following things:
- Progress Note
- Further Plan of treatment
- Final Bill Discharge Card if For Discharge
7. With Reference to that My doctor Replied that Diffuse non Erosive Gastritis & migraine has been diagnosed and as the patient condition is improving we are putting him on oral medication and planning to discharge on 12-09-09.
8. As reply to this Claim Was denied stating “ AS PER GIVEN CLINICAL PRESENTATION, HISTORY WE ARE UNABLE TO CONSIDER HOSPITALISATION AND CLAIM. INVESTIGATIONS ARE IN NORMAL LIMITS ORAL MEDICATION CAN BE GIVEN ON OPD BASIS. “
9. ON 12-09-09 I had vomiting of blood in form of hematemesis, As the condition was detoriating And considering clinical presentation was not justifiable I asked my doctor to send detailed report with all description.
My doctor sent Detailed letter stating following thing:
- Patient was taking OPD medication for pain in abdomen and head from Dr. V.K. Thorat
- Patient Got admitted on 08-09-09 in emergency condition and MRI, Gastroscopy , CT scan and Colonoscopy was done as Patient had severe unbearable pain in abdomen and Head.
- Patient was kept on IV initially, as the patient condition was improving we kept the patient on oral medication. But on 12-09-09 patient has developed upper GI BLEEDING in the form of Haematemesis and now is kept on IV Fluid, IV Pantocid & Nil BY Mouth(NBM) for next 48 hours.
- All prescription of the OPD was also sent as scan copy where in it was mentioned that on 16th-08-09, Patient has done social drinking in very low amount.


10. Again denial of the Claim came Stating that “ Patient Is Ethanolic & admitted in Gastritis”.
11. In reply to this My doctor sent a letter to Paramount stating Following this

a. Patient was admitted in Poona hospital in Emergency Condition and is At IV, Disease id No Way related to alcohol as he is not an addict. He will need to continue as hospitalized till oral intake is possible.

12. When I Called Customer Care to take status of the Case, They told that this case is transferred to Pune and sometime later I called at pune office , as they heard my name they kept my call on Hold for almost 30 minutes then again I called there was no response from them.
13. For further discussion, I called my HR for Follow up as my condition was not in good condition.
14. Then a Conference call was organized in which included following people

a. Bhavna, HR Eclipsys India Pvt. Ltd.
b. Shivani , First Policy Help Desk (First Policy is the consultant appointed for Med claim).
c. Dr. Sanjay, Paramount Health Services who made decision on the issue.
d. Dr. V. K. Thorat, My care provider doctor.

15. Doctor Thorat explained the situation where in I was admitted and justified that admission was required for this patient. Going Forward He also explained that Patient Is not addict to alcohol and this disease is not the reason for gastritis as the patient took alcohol 21 days back.

16. Dr. Sanjay agreed on all facts but still said that still we cannot consider the case for Cashless.

17. I feel harassed as I had to do lots of discussion even in condition when I was not in condition to speak as I was on IV from last few days. My doctor justified the condition and as per policy this satisfy the condition of the Cashless facility but still this was not considered, as in that condition I had to be mentally tensed to raise funds for the bill of 50 K in hospital.

18. As I didn’t have enough money, I had to take discharge from hospital even in bad condition on follow up advice. I feel harassed in this.

19. Please help me so that my claim can be considered.

MY PHS ID is IL PUN 10747255 ECLI E
PATIENT NAME: HIMANSU PATHAK

Regards,
Himansu Pathak
9673330731

Hey guys this has been resolved
now 42 k (approx)out of 50 k(approx) has been re-imbursed.