??????????? rejection ??????????? rejection

1. महोदय आप द्वारा मेरे अनुरोध को सिर्फ एक क्लॉज का आधार लेकर रिजेक्शन का निर्णय कर दिया गया ,मैं आपके इस निर्णय से संतुष्ट नहीं हूं ।
2.आपने सिर्फ एक क्लॉज को ध्यान दिया जिसमे hospitalization 24 घंटे से कम हैं ।
3.आप द्वारा यह बताया गया कि मैं कोविड के इलाज के लिए भर्ती हुआ था।
4.जबकि सत्यता यह है कि बुखार और कमजोरी के कारण बेहोश होने पर मुझे अस्पताल में भर्ती होना पड़ा।
5. वहां जांच में पता चला कि मैं कोविड से पीड़ित हूं ।
6. भारत सरकार की गाइडलाइन के अनुसार अपोलो हॉस्पिटल में कोविड हॉस्पिटल ना होने के कारण मुझे मजबूरी वश वहां से डिस्चार्ज होना पड़ा जबकि मैं बहुत अस्वस्थ था और मुझे हॉस्पिटल केयर की आवश्यकता थी।
7.महोदय हॉस्पिटल द्वारा मुझे आईसीयू में रक्खा गया और उनके द्वारा 24 घंटे के मापदंड के आधार पर बिलिंग की गई थी।
8.महोदय गत आठ वर्ष से मैं हेल्थ इंश्योरेंस का प्रीमियम का भुगतान इसी आशा के साथ कर रहा था कि जब मुझे इसकी आवश्यकता होगी मुझे इसका फायदा मिलेगा।परंतु आप के निर्णय से मुझे अत्यधिक मानसिक पीड़ा का अनुभव हो रहा हैं।
आपसे निवेदन हैं कि उपरिलिखित बिंदुओं को दृष्टिगत रखते हुए मेरे अनुरोध पर पुनः सम्यक विचार करते हुए मेरे रेमबर्समेंट के अनुरोध को स्वीकार करते हुए उचित एवं आवश्यक कार्यवाही करने की कृपा करें।
धन्यवाद
भवदीय
आशीष मिश्र।


On Thu 20 May, 2021, 12:32 PM , wrote:
Manipal Cigna

Date: 20 May 2021

Reimbursement claim request for your ManipalCigna_ProHealth Insurance Plus_Non Floater policy number PROHLN000488554_2020
Dear Ashish Mishra,

This is with reference to your reimbursement request for the aforesaid policy number, we regret to inform you that we are unable to approve your request currently for Ashish Mishra registered under Claim Number 24569222 on 06-05-2021 08:08:10 hospitalised at Apollo Medics Super Speciality Hospitals for COVID-19, virus identified due to the following reasons.

What are the claim registration details?

1. Claim Number: 24569222
2. Patient Name: Ashish Mishra
3. Hospital Name: Apollo Medics Super Speciality Hospitals
4. Hospital Address: Plot no. KBC, 31, Kanpur - Lucknow Rd, Sector B, LDA Colony, Lucknow, Uttar Pradesh 226012
5. Ailment for which admitted: COVID-19, virus identified
6. Insurer Claim No:
7. Insurer Member Id: 1001388653
On scrutiny of the documents it has been observed that We have received claim documents for, claimant Mr Ashish Mishra admitted at Apollo Medics Super Speciality Hospitals on 03 Apr 2021 (TOA 06:01a.m) and discharged on 03 Apr 2021 (TOD 13:38 p.m ) with complaints of COVID 19 +ve . Claimant is covered under ManipalCigna Health Insurance Prohealth (Plus) policy since 16 Jul 2020 .As per Discharge summary it is evident that hospitalization is less than 24 hours, hence the claim stands repudiated under the Policy Clause II.1. Inpatient Hospitalization. We regret our inability to admit this liability under the present policy conditions. We also reserve the right to repudiate the claim under any other ground/s available to us subsequently.

With regards to the same, we request you to read the policy document and refer to the clause mentioned below:

DenialClauseID Description
II.1 II.1. Inpatient Hospitalization: We will cover Medical Expenses of an Insured Person in case of Medically Necessary Hospitalization arising from a Disease/ Illness or Injury provided such Medically Necessary Hospitalization is for more than 24 consecutive hours.
At ManipalCigna, we are committed to superior customer satisfaction, and we ensure that the quality of services and products is at the best level.

You can reach out to us on our helpline number 1-800-10-24462, write to us on [email protected] or visit our nearest ManipalCigna Health Insurance Branch and you will be assisted for any information you may require.

If you wish to report a grievance, please write to us on the options as suggested below. You will receive a resolution within 15 days of we receiving your communication.

Level 1: You can connect with our Health Relationship Managers by

Calling our Toll Free Helpline: 1800-102-4462 between 9:00 AM to 9:00 PM.
Or write to us at: [email protected]
You can also submit your letter to us at:
Grievance Management Cell: Address: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai-400063.
Escalation Mechanism:

If the resolution you receive does not meet your expectations, you may escalate your grievance at the levels mentioned below. As prescribed by the Regulator, you will receive a resolution within 15 days of us receiving your communication.

Level 2: Please write to our Grievance Redressal Officer at [email protected]

Level 3: Please write to our Senior Grievance Redressal Officer at [email protected]

Level 4 : If the channels above have still not met your expectations, you may approach the insurance ombudsman, the office Name and address details applicable for your state can be obtained from the following link https://www.irda.gov.in/ADMINCMS/cms/NormalData_Layout.aspx?page=PageNo234&mid=7.2 on the IRDA Website

Note:

If you are not satisfied with the decision provided by any of the above authorities, you can approach the company within 8 weeks from the date of receipt of response by the insured/policyholder. Incase no response within 8 weeks your grievance will stand close.
You may also approach the Insurance ombudsman if your complaint is open for more than 30 days at any of the above levels.
Assuring you of our best services at all times.

Yours sincerely,

ManipalCigna Health Insurance Company Limited

***** This is a system generated certificate which requires no signature *****
CignaLetterFooter
1. महोदय आप द्वारा मेरे अनुरोध को सिर्फ एक क्लॉज का आधार लेकर रिजेक्शन का निर्णय कर दिया गया ,मैं आपके इस निर्णय से संतुष्ट नहीं हूं ।
2.आपने सिर्फ एक क्लॉज को ध्यान दिया जिसमे hospitalization 24 घंटे से कम हैं ।
3.आप द्वारा यह बताया गया कि मैं कोविड के इलाज के लिए भर्ती हुआ था।
4.जबकि सत्यता यह है कि बुखार और कमजोरी के कारण बेहोश होने पर मुझे अस्पताल में भर्ती होना पड़ा।
5. वहां जांच में पता चला कि मैं कोविड से पीड़ित हूं ।
6. भारत सरकार की गाइडलाइन के अनुसार अपोलो हॉस्पिटल में कोविड हॉस्पिटल ना होने के कारण मुझे मजबूरी वश वहां से डिस्चार्ज होना पड़ा जबकि मैं बहुत अस्वस्थ था और मुझे हॉस्पिटल केयर की आवश्यकता थी।
7.महोदय हॉस्पिटल द्वारा मुझे आईसीयू में रक्खा गया और उनके द्वारा 24 घंटे के मापदंड के आधार पर बिलिंग की गई थी।
8.महोदय गत आठ वर्ष से मैं हेल्थ इंश्योरेंस का प्रीमियम का भुगतान इसी आशा के साथ कर रहा था कि जब मुझे इसकी आवश्यकता होगी मुझे इसका फायदा मिलेगा।परंतु आप के निर्णय से मुझे अत्यधिक मानसिक पीड़ा का अनुभव हो रहा हैं।
आपसे निवेदन हैं कि उपरिलिखित बिंदुओं को दृष्टिगत रखते हुए मेरे अनुरोध पर पुनः सम्यक विचार करते हुए मेरे रेमबर्समेंट के अनुरोध को स्वीकार करते हुए उचित एवं आवश्यक कार्यवाही करने की कृपा करें।
धन्यवाद
भवदीय
आशीष मिश्र।


On Thu 20 May, 2021, 12:32 PM , wrote:
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---------- Forwarded message ----------
From: Ashish Maths Wala
To: [email protected]
Cc:
Bcc:
Date: Wed, 26 May 2021 23:27:14 +0530
Subject: Re: Reimbursement Rejection Under ManipalCigna_ProHealth Insurance Plus_Non Floater policy number PROHLN000488554_2020
----- Message truncated --

Kishan Dutt Kalaskar Retired Judge

Responded 1 year ago

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A.Dear Sir,
Please simply your question in one paragraph.
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Abhimanyu Shandilya

Responded 1 year ago

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A.Dear sir,
These kind of rejections are very common by the insurance companies for small reasons. I would suggest that you can build your case against them, hire a good lawyer and then file a case in consumer forum. This way you can not only get your insurance claim but also you can seek compensation for the mental agony that you have gone thru for all this.
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Anik

Responded 1 year ago

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A.Hey,
If your situation doesn't fall under clause 11.1 of your insurance policy and filing by the hospital is done wrongly then please reach out to the insurance ombudsman and write a complaint to him about the hospital and this issue of your and see if a solution come out. Or else you can send the legal notice to hospital with help of the lawyer to the hospital and settle your claims.

If you find my answer useful then please rate my answer. Thank you
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Ayantika Mondal @ Prime Legal

Responded 1 year ago

A.Hey,
Scrutinising the above clause the medical insurance company is well under the scope to reject your plea for compensation of your medical expense but you can try reaching out to the an explain your situation or even contact insurance ombudsman for your claim.

If you find my answer useful please rate my answer. Thank you
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