Consumer Redressal

Policy No. : GHS/Q0060058/11 Member Id : BA1301000438CAREF Name : Payal Mody I was admitted at Max Hospital Gurgaon on 18th Sep 2014 for a surgery through cashless facility for the treatment of cervical erosion. My treatment was pre approved by Raksha TPA and they approved 35000. On the pre authorization form the hospital TPA desk had mentioned that per day room rent is 7000. The hospital received the approval from Raksha TPA on 17th Sep 2014 and on that approval letter my room eligibility was no where mentioned. At the time of my discharge on 19th Sep 2014, the hospital sent the final bill to Raksha TPA. At that time Raksha TPA approved only 12535 towards treatment expenses, on that letter they informed about my room eligibility and passed the amount as per eligibility. They should have informed this on the first day itself (before admission) rather they informed this on the discharge day. I immediately contacted our TPA coordinator Mr. Balvinder, he said that due to some technical fault the room eligibility was not printed. On assurance from Mr. Balvinder I paid the balance amount to the hospital since he assured that he will get my medical expenses reimbursed as the fault was from their side. Since then I am following up with Mr. Balvinder but he has been giving false commitments since 19th Sep and has done nothing so far. I fail to understand why did they initially approved my hospitalisation and treatment charges and then later not paid the amount. On the first day itself they should have informed about my entitled room category and should have passed the amount as per that entitlement. I would have never got my treatment done at Max Hospital if my medical expenses were not approved from Raksha TPA. This is a clear case of negligence by misleading and hiding details from the patients. Raksha TPA is solely responsible for all this confusion. 1. On the pre-authorization form the Hospital TPA desk clearly mentioned 7000 per day room charges and estimated cost of the treatment based on the room rent. 2. Raksha TPA should have not approved the room rent if I was not eligible to it or they should have mentioned my eligibility on the pre approval letter but on contrary they approved 35000 without updating the criteria or eligibility. 3. Moreover to cover up their negligence the Raksha TPA coordinator for my Company said that "we always mention the room eligibility on the approval form but in your case it was not mentioned due to some technical fault". Am I responsible for the technical fault at your end, if not then why should I bear the expenses. Please acknowledge the email . In anticipation of a positive revert.