Cashless Facility Denied by Paramount Health Services with Invalid Reason and later with much hassle only provided partial cashless and even retracted back some of the cashless they provided!!!

1. My father (Dr. R. C. Gupta) has Reliance General Insurance through his university (GLA University Mathura) – where the TPA is PHS.

2. He gets admitted to Medanta - Medicity Gurgaon for an injury (fracture revision total hip replacement due to a fall at home) on Nov 18th 2011.
3. Papers are filed for cashless (total eligible amount is 3lacs)

4. PHS personal (Dr. Manoj) comes for inquiry to the hospital – even sees the patient to make sure it’s a genuine case. PHS declines (Dr Amit) cashless and the letter has no reason at all listed in the cashless decline letter.

5. We call multiple times and the reason we are given after multiple calls (Mr Danish) – was that there was some confusion on the actual date of injury in the doctor’s report. This error is promptly rectified by the doctor’s office (Dr. Vivek Sharma) and a letter is sent to PHS with the corrected date of injury (Nov 17th 2011).

6. This should have been enough to approve but PHS send back the same denial letter – with a hand written note on the same paper saying “Still Denied” with no reason whatsoever – extremely unprofessional. At this point we were all very worried and tied up with regards to the major surgery my dad was undergoing.

7. Multiple folks called PHS (Hospital, University, Reliance etc.) – we asked them for the reason of decline. Later they sent a letter asking for information from doctor (date of injury and circumstances etc.) which the doctor promptly sent.

8. After this the next day they sent a note of 1.5 lacs cashless (eligible amount was 3lacs).

9. Again folks from reliance and university contacted PHS and asked why not the full eligible amount was approved (the final bill was around ~3.84 lacs).

10. PHS kept saying they will provide full eligible amount as the day of discharge nears.

11. In the next couple days they provided 50k more cashless + additional 10k

12. On the final day of discharge they retracted the 50k cashless which they had provided earlier which was shocking (I am not even sure if it is legal to retract the already provided amount!!) and only provided 7.1k. Total approval is 1.67 lacs.

My family feels shocked and harassed by our recent encounter with the PHS TPA. We are a family of well accomplished doctors and management professional and I in particular having lived outside India in the past have experienced superior medical and health insurance services. We were aghast when we saw how the process works in Paramount Health Services and how it is misused to deny genuine cases. If this continues heath care will be the biggest scam in India shadowing 2G spectrum, commonwealth games etc.

My sincere request is to not to play with people’s sentiments – more so when they are in a vulnerable situation and admitted for treatment – the patient and his/her family are already going through a lot of physical and mental agony – please spare them with this unnecessary hassle. I urge the management and the authority to look into this – I hope to get my eligible amount reimbursed – but above and beyond this I want to bring to this to notice with the right teams so that others in similar situation are not subjected to this.

Patient Name: Dr.(Prof) R. C. Gupta
PHS ID: RG VRI 12482347 GLAU E
Hospital: Medanta – Medicity Gurgaon.
Sincerely,
Gupta Family
Contact: shefug@gmail.com