Mediclaim rejected for Hospitalization of my Mother.
Hi,

I work with Freescale Semiconductor and we have a Mediclaim Policy with HDFCergo through Paramount Health Services(PHS) as TPA.I would like to register my complaint against PHS and HDFC Ergo.

PHS ID :- 2501197
Patient Name : Radha Devi


My Mother Complained of acute gidiness,headache and difficulty in walking in Early mroning Hours.I took her in Emergency to the Fortis Hospital Faridabad at 6AM in the morning.The doctor on duty tried to make her stable by some Injection and other treamtent but didn't find any improvement in her condition.She was not able to even sit on her seat.
As a result the Doctor advised us to admit her.

she was admitted and again examined by the Neurologist doctor for Cerebeller signs such as Tendom Walking, Knee heal etc.The Doctor informed us that she may be suffering from Acute Virtigo(Posterior Circulation TIA) and adviced us to get the tests like MRI,CT Scan,Blood and Urine tests.All of the tests done were incidental to the problem which my mother reported.Her MRI reports were normal.The Doctor Suggested to keep her under observation for some time.She was kept on antivertigo treatment along with other Symptomatic treatment.

After observing her condition to be stable and after 28 Hours of hospitalization,we opted to Discharge her.She was discharged on request with follow up Medical Prescription advice(such as Ecosprin) for 5 days and again consult the doctor.

The Insurance company rejected the hospitalization with a note that "Hospitalization was primarily for Investigation
and hence can't be compensated.The Investigations could have been done as per OPD".

How can they say that we went primarliy for investigation and these could be done as a part of OPD?

1)I had to admit my mother in Critical Condition.She was in no condition to even sit and So how can the insurance comapany expect me to wait for the day to get her diagnosed in the OPD for the same.

2)Secondly I took her to the Emergency ward where she was given some basic treatment, but her condition didn't show any improvemt even after one hour.As a result,only on the advice of the Doctor,I admitted her in to the Hospital.

3)All the tests that were carried out were incidental to the ailing condition of my mother and were conducted on the advice of the Doctor.

4)Also note that FORTIS is a listed hospital by the Insurance Provider.


Please suggest me how can I take this battle forward through the Consumer Court platform.The whole process has been a mental torture for me.Even during the hospitalization of my mother,I spent crucial hours hanging around the TPA guys to get a cashless claim for the same.I was working like a co-ordinator and messenger between TPA and Hospital Staff.
These guys are trying to prove a genuine hospitalization to a false claim of mainly for Investigation.

Regards,
Rajeev Sharma
9910036241