Complaint Details

Status	:	Closed
Complaint No	:	0087109/2016
Category	:	Insurance
Date	:	23-09-2016
Subject Line	:	Raksha TPA made settlement of Rs.2,01,468/- with Forties Hostital bill of Rs.4,47,264/- against the Policy of Rs.Three Lacs.
Complainant	:	Bipul Hazarika
Address	:	HN#49, WEst Nabagraha, P.O.- Kharghuli
Complainee	:	Raksha TPA Pvt. Ltd.
Address	:	Prag Plaza, Near HUB super market, 2nd floor, Bhangagarh.

Complaint Details
To Date:23/09/2016
Sir/ Madam,
Subject: Raksha TPA had Settled claim for rupees 2,01,468/- against total sum insured policy of rupees 3,00,000/- of Policy # 321300/300/48/2017/957 of Oriental Insurance Co Ltd.
Dear Sir,
I have undergone a Brain Tumor surgery on 7th September 2016 at Forties Hospital Gurgaon & the total bill was amounting to Rs.4,47,264/-. My Mediclaim policy # 321300/300/48/2017/957 has total claim of Rs.3,00,000.00 under Oriental insurance Co Ltd which I had informed through mail about the claimed on 12/09/2016 & submitted all the bills & required documents at the Raksha TPA office Bhangagarh on 16th September 2016.
Now Raksha TPA Pvt Ltd had made a final settlement of Rs.2,01,468/- for Forties hospital Gurgaon’s total bill of Rs.4,47,264/- after making a deduction of Rs.2,45,796/- against my total sum insured policy was for Rs.3,00,000/-.
The main reason for DEDUCTION was “DEDUCTED AS PER HIGHER ROOM CATEGORY” under the heads like Anaesthesia Charges, Surgen Fees, Consultant Charges, Investigation Charges, Hospital Services, Operation Theatre Charges, RMO/Nursing.
Expense Name BilledAmt Deduction Approved Reason of Deduction

Single Room 21000 12000 9000 12000/- DEDUCTED AS PER DAY ROOM NURSING LIMIT
ICU Charges 12000 6000 6000 6000/- DEDUCTED AS PER DAY ICU LIMIT EXCEEDS ,

Anaesthesia Charges 31410 17904 13506 17904/- DEDUCTED AS PER HIGHER ROOM CATEGORY ,

Surgen Fees 146580 83551 63029 83551/- DEDUCTED AS PER HIGHER ROOM CATEGORY ,

Consultant Charges 8900 5288 3612 500/- NUTRITION FEE 4788/-DEDUCTED AS PER HIGHER ROOM NURSING LIMIT EXCEEDS

Investigation Charges 35656 31679 3977 1390/- HIV,1025/-HBSAG,200/-GLUCOSE RANDOM NONPAYABLE
INVESTIGATION, 11100/-03/09/16 INVESTIGATION PRESCRIPTION &
REPORTS NOT ATTACHED,1050/-ABG,11640/-CNS TUMOR REPORTS
NOT ATTACHED,5274/-DEDUCTION AS PER HIGHER ROOM
CATEGORY ,

Hospital Services 9041 5153 3888 5153/-DEDUCTED AS PER HIGHER ROOM CATEGORY ,


Non-Medical Items 4570 4570 0 1500/-MRD CHARGE 2000/-DIPOSABLE & PREPARATION MAJOR 90/- DONATION 980/-FOOD CHARGE ,

Operation Theatre Charges 88995 50728 38267 50728/-DEDUCTED AS PER HIGHER ROOM CATEGORY ,

RMO/Nursing 1000 570 430 570/-DEDUCTED AS PER HIGHER ROOM CATEGORY ,


It is really very surprising for me and I never knew before during purchasing the policy that “HIGHER ROOM CATEGORY” would have effect on (1) Anaesthesia Charges (2) Surgen Fees (3) Consultant Charges (4) Investigation Charges (5) Operation Theatre Charges. This was a major brain tumor surgery & the charges/ fees which are 100% genuine & reasonable in private Hospitals/ Medicals of India as per the Indian medical society. The above mention heads has a bill of Rs.3,11,541/- and Raksha TPA had made a payment of Rs.1,84,752/- after deducting Rs.1,26,789/- i.e. 40% deduction of the total bill which is not acceptable at all against my total sum insured policy was for Rs.3,00,000/-.
I JUST WANT TO KNOW IN WHICH PART OF INDIA SUCH A MAJOR BRAIN TUMOR SURGERY CAN BE DONE AT A COST OF RUPEES TWO LAKS ONLY? WILLN’T IT COST MORE THEN RUPEES FOUR LAKHS ANYWHERE IN INDIA?
WHAT IS THE USE OF DOING A MEDICLAIM POLICY OF RUPEES THREE LAKHS IF I DON’T RECEIVE THE FULL AMOUNT?
I WASN’T INFORMED BEFORE ABOUT THE DEDUCTION OF “DEDUCTED AS PER HIGHER ROOM CATEGORY”
I AM A COMMON GENERAL PEOPLE & I DON’T HAVE MUCH KNOWLEDGE ABOUT YOUR POLICIES, RULES, PROCEDURE OF YOUR DEDUCTION ON “HIGHER ROOM RENT CATEGORY” WHICH YOU NEVER INFORMED/COMMUNICATE WITH ME BEFORE IN THE LAST 5 YEARS OF MY POLICY LIFE.
HOW DOES & WHAT IS THE LOGIC OF “HIGHER ROOM RENT CATEGORY” DEDUCTION EFFECT ON (1) Anaesthesia Charges (2) Surgen Fees (3) Consultant Charges (4) Investigation Charges (5) Operation Theatre Charges since charges/ fees, SINCE ALL THE EXPENSES ARE SAME EVERYWHERE IN INDIA WITH SUCH A MAJOR & CRITICAL DISEASE.
So Please advise me what should I do now if I will have to get Rs.3,00,000/- as per the total sum insured policy of Rs.3,00,000/-.


Thanking you,
Your sincerely,
Bipul Hazarika
Kharghuli
9613872828

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