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NOT PAYING MEDICAL REIMMBERSMENT BY MEDICARE/ORIENTAL INSURENCE

Location/place: KOLKATA

Name of company/service: govt employed

NAME :SUBHENDU DAS
POLICY NO: 311400/48/2010/6534 ,
Member NO: 09I00484845A
CLAIM NUMBER :06105423,CLAIM AMOUNT RS:53820/-
TPA :MEDICARE TPA SERVICES.

Sir
I am a 35 yrs old mediclaim policy holder of Oriental Insurance since 27.01.2006 for Rs 2 Lakh per annum with Medicare as my TPA.Since begining for last four I have not made any claim.
In January 2010 I suffered from high fever and vomiting for which I had to be admitted ON 24TH JANUARY,2010 at MIDLAND NURSHING HOME PVT LTD at Rathtala ,Kolkata under Dr P.P.Ghosh(M.D).
My condition deteriorated and I had to be trasffered to SSKM hospital on 04.02.2010.I recovered from SSKM and was discharged on 26.02.2010. with the following diagonosis
1.ACUTE RENAL FAILURE.
2.ACUTE VIRAL HEPATITIS.
3.LRTI
While in Midland N.H. I appilied for cashless service which was denied on the ground of alcohol abuse
though neither I gave such history nor the treating Physician & nephrologist has written off.
After my discharge I applied for reimbursement on 08.04.2010 of around RS 78000/-(SEVENTY EIGHT THOUSAND ONLY)
I received a check of RS 3960/-(Claim number 6102871 date 12/07/2010, ref number 6102871-15294) FROM MEDICARE in which it has been written that ” as per transfer summary of Midland N.H. the member was staying from 24.01.2010 to 04.02.2010 in the N.H. but as per policy schedule the closing date of policy for the year 2009-2010 is 26.01.2010.Hence expenses after 26.01.2010 is payable…. in next policy year (2010-2011)”……IT SHOULD BE MENTIONED that I renewed my policy for this period in due time…(POLICY NUMBER 311400/48/2010/6534)..The settled amount is around Rs: 54000/-
Meanwhile I got a letter from Medicare dated 14.07.2010 that they need a copy of first consultation (which I already gave during claim) and treating physician to certify the history of alcohol abuse in his letter pad with his registration number.I submitted it on 26.07.2010(Dr Rajen Pandey, Nephrologist and Dr P.P.Ghosh BOTH OF WHOM AND THE DOCTORS OF SSKM Hospital has clearly written that there was no history of alcohol abuse or any other addiction. .
Sir, it is giving me immense pain that not only I have been denied of my claim but also I am been defamed.There was no hostory of alcohol abuse which was time and again documented by my treating physician at Midland Dr P.P.GHOSH(M.D.),DR RAJEN PANDEY(M.D,D.M Nephrology,) as well as in my discharge summery from SSKM hospital.In fact no one came and talked to me on Medicare part.
More than that how come I got the above mentioned check of lesser amount and can’t get the other check for the same disease?
So I request you to kindly settle my matter as early as possible and oblige.
Thanking you

Subhendu

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