BACK GROUND:

My Name: S ANANDAN
Address: 341/B3A, 2nd Floor, Janakpuri, New Delhi - 58
Email: s.anandan@bharti-infratel.in, s_anandan2000@rediffmail.com
My Contact No.: 9871057741, 9958100161
Mediclaim Insurer: UNITED INDIA INSURANCE CO. LTD, Chennai
Mediclaim Policy No.040700/48/10/41/00001293 issued on 14.7.2010 & Valid till : 13.7.2011
Registered Compliant No.WB-3035 (with the Insurer)
Registered Compliant No.ICF12307 (with Indian Consumer Forum)

With a severe pain in the abdomen, on 21st Apr. 2011, I was admitted to ORHCID HOSPITALS (Janakpuri-Delhi) which is one of the approved hospitals by TTK HEALTH CARE PVT LTD. I had chosen to clear the hospitals by CASHLESS mode. On 21st Apr. 2011 itself, the reason for the pain was diagnosed as "acute calculus cholecysitis with gangrene of GALL BLADDER & massive adhesion". Based on the diagnosis, it was proposed to perform an operation through LAPRASCOPY at an estimated cost of Rs.30000/- (which was approved by TTK). While performing the operation, i.e. at the final stage of the LAPRASCOPY operation, it was redecided to perform an OPEN surgery, since the case became more complicated. The total duration of the operation was 6-7 Hrs for both the type of operation. Initially, it was proposed as STONE REMOVAL from GALL BLADDER but lookin at the severeness of the case, they have removed the GALL BALADDER through an OPEN surgery following the laproscopic procedure. The operation became successful & I was put in the ICU for further 30 Hrs. I was discharged on 26th Apr.11.

Due to the dual process of operations (laproscopic & the open suregey), the cost of the whole treatment/hospitalization has exceeded over initial estimation which was made for just one type of Operation. It is also proven that the cost of the operation would have not exceeded if it would have done with the LAPRASCOPY. The total cost has exceeded the initial estimation because of additional surgeon fee, extended ICU care, extended Anesthesia, extended Room Rent & other vital services/medicine. I would have been discharged on the next day of the operation as initially proposed.

Initial Cost Estimation Rs. 30,000 which was Approved by TTK for the Laprascopy operation (for the Stone removal)

Additional Cost 50,000 which was denied by TTK for the Surgery operation (for the removal of the Gall Bladder)

RESPONSE FROM TTK HEALTH CARE PVT LTD:
TTK had approved an amount of Rs.30000/- which was just for Laprascopy operation. TTK also claimed that the Surgery operation was not necessary & it was deliberately done by the hospital & they have denied the approval for the additional cost of Rs.50000/-. I was told to pay from my own. I have paid Rs.50000/-. Also, the TTK has claimed that the information on decision performing the Surgery operation was not shared by hospital on-time.

COUNTER-RESPONSE BY THE HOSPITAL:
The Hospital has made very it clear that looking at the life of the patient, the Surgery operation was necessary as the case became more complicated. Also, the hospital has explained that any associated problem is automatically required to be covered under Mediclaim Policy. Also, the hospital has argued that TTK has applied only a CAP of Rs.30000/- for the STONE REMOVAL through a Laprascopy operation. & the TTK has to apply additional CAP for Rs.50000/- for the Surgery operation which was very much necessary for removing the Gall Bladder.

MY CONERN:
Firstly, the hospital is a TTK approved hospital which has obviously huge credential which made decided me to choose. Now, any dispute between the hospital and the TTK should not be a part of the patient. Also, if the hospital is not able to convince TTK, the patient should be affected. TTK should ask either the hospital to reduce the bill to extend of the approval if the TTK is not convinced by the hospital or they need to apply an additional CAP of Rs.50000.

Secondly, (if TTK claims that the Surgery operation was done deliberately) TTK should further investigate thoroughly that how the complication was missed in the initial estimation? Was the complication not visible enough in the diagnosis? If the act of deliberation is not established, then TTK should apply additional CAP for Rs.50000/- for the Surgery operation. If the act of deliberation is established then TTK should direct the hospital to remove the additional bill of Rs.50000/- which was not estimated.

The TPA-TTK has denied to settle the expenses incurred towards open surgery conducted by the doctor following the laproscopic procedure. The hospital/attending doctor has stated that the situation and condition of the patient warranted that the surgery be performed. This can be verfied from the doctor/surgeon's statement

I look forward to hearing from you in the matter.

S ANANDAN