Complaint Details

Status	:	Closed
Complaint No	:	0006516/2013
Category	:	Insurance
Date	:	26-09-2013
Subject Line	:	Maxbupa denied my health claim
Complainant	:	Noormohmed Haju
Address	:	109, D-Wing, Gulab Park-3, Sharifa Road, Amrut Nagar
Complainee	:	Maxbupa Health Insurance company Ltd.
Address	:	Max Bupa Health Insurance Company Limited, 2nd Floor, Salcon Ras Vilas, D-1, District Centre, Saket,

Complaint Details
I would like to file a complaint against Maxbupa health insurance company ltd. for denial of my cashless hospitalization claim. My wife needs to get laparoscopic cystectomy surgery done immediately. I had claimed vide preauth ID No. 29445 which is denied by Maxbupa health insurance company Ltd. as they are saying that this is a possibility of pre existing disease and cannot be ruled out and liability cannot be established.

I have emailed the doctors justification letter to customercare@maxbupa.com clearly mentioned that "prior existence of this cyst is not known as no sonography was done prior to February 2013" but I haven't received any reply from their side yet.

I hereby clarify that this is not pre existing disease as it is not detected before the inception of policy and should be covered under cashless hospitalization. I have attached the doctor's letter mentioned that Ovarian Cyst was detected in February 2013. She had minor pain in abdomen since two months before doing the first sonography in February 2013 and the policy commencement date is 11/10/2012 and existence of this cyst is not known as no sonography was done prior to February 2013.

Repeatedly calling their customer care number on 180030103333 I go reply from their executives that my claim is denied as it is pre-existing condition and cannot be reconsider it again. They keep advising me that get patient admitted in hospital and get the surgery done and submit the papers for re-reimbursement.

Here are my few questions to ask:
1) If the disease is not detected before the inception of the policy then how it comes under the pre-existing condition?

2) Maxbupa stated in claim denial letter that "CASHLESS IS DENIED AS POSSIBILITY OF PED", my question is do their doctors work on just doubt basis or consider the claim as per patient's doctor letter. (I am sure patient's doctor better know what and how long their patient has disease and not the insurance company's doctor)

3) Why should I settle the hospital bills as I have the cashless claim and if they cannot reconsider the cashless claim then why they didn't mentioned in my policy letter.

Sir, I have no money to pay hospital bills and I am totally depend on this cashless hospitalization.

I hereby request your honor to look into this matter, so I can get my wife's surgery done in time.

Awaiting for your valuable reply soon.
Thanks.

Mr. Noormohmed Ahmed Haju
Maxbupa Customer ID : 0000167127
Patient's name: Neelam Haju
Date of Birth: 28/03/1980
Contact Phone : 9920148378

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