- Max Bupa denied the payment of Mediclaim ^Open

ANTRIKSH BHASKAR filed this complaint against Max Bupa Health Insurance on Aug 03, 2018

Detailed history of the case
*. On *.*.** , my wife Mrs. Isha Bansal purchased a Mediclaim Family Floater Policy of Rs. **.* Lakh Mediclaim (Policy No. **************) cover from Max Bupa, by paying the premium Rs. *****.**.

*. The persons covered under this policy are Isha Bansal and (her husband) , Me ; Antriksh Bhaskar.
*. As per Policy terms :-
a. Initial waiting period for any claim was ’** Days’.
b. Waiting period for other major medical problems claim was ‘* Years’.
c. Waiting period for claim related to pre existing disease was ‘* Years’.
d. However claims like accidental injuries are covered from **st day.

*. On *.*.**, I, (Antriksh Bhaskar) while coming back from my coaching class on my motorcycle met with an accident to avoid a dog, who suddenly came in front of my motorcycle.

*. I was taken to Kailash Hospital & Heart Institute of Sector – **, Noida and was attended by one Dr. M. M. Piplani (Orthopaedic Surgeon). They also took my Knee X-Ray and MRI of Right Knee joint.


*. In these it was found that due to that accident I have suffered from “Fracture of medial and lateral tibial condyles with intra-articular extension with marrow edema in surrounding bones.

*. Doctor immobilized the leg and advised me for an Operation for the same.


*. To take a second opinion, I visited Fortis Hospital, Sector – **, Noida on *.*.** and consulted with Dr. Atul Mishra, Director Arthroscopy & Knee Surgery. Dr. Atul Mishra also advised him Arthroscopic ACL Fixation Surgery and also told me that this surgery can be done only after the resolving of inflammation of leg, which may take **-** days. He further advised that till that I should not move my leg and rest on the bed with knee brace.

*. On my request , he agreed to do this operation in Kailash Hospital, as Kailash Hospitalis is more near and also cheaper than Fortis Hospital.


**. On *th April, I again went to Kailash Hospital to take the date for operation.

**. For Surgery, I was admitted in Kailash Hospital on **th April and Kailash Hospital sent request for pre approval of the treatment to Max Bupa.


**. Max Bupa replied that cashless can not be sanctioned as they need some more enquiry, but also wrote that, “Denial of cashless not to be considered, denial of treatment”.

**. After this I was operated on **.*.** and subsequently discharged on **.*.**. Following points were mentioned in my Discharge Summary.
Final Diagnosis at Discharge : H/o Fall followed by Fracture of medial and lateral tibial condyles.
Procedure / Operation Done :- ACL fixation and Meniscal repair (Rt.) done on ** .*.** under SA.

**. Total Bill of Kailash Hospital was Rs. ****** .**. It was sent to Max Bupa. They replied that they are going to do some more enquiry, hence they can not pay the bill right now.

**. I got the Bill pending by giving the guarantee of some local person with the hope that Max will pay it in *-* days.
**. But because Max did not paid and on the demand of Kailash Hospital, I paid the Bill on **.*.**
On **.*.**, Max Bupa informed my wife Mrs. Isha by email that I (Mr. Antriksh Bhaskar) was suffering from some knee problem since Dec. **** and it was not disclosed at the time of purchasing the policy, so they are rejecting the claim. They wrote;
“This is with reference to your health insurance policy number ************** for which we have received Pre-auth / Reimbursement Claim request Id ******.We would like to inform you that during processing of the claim the below mentioned medical condition/s has been identified which was/were not disclosed to us at the time of applying for health insurance policy”

 Antriksh Bhaskar   known case of instablity knee dec **** 

**. They also threatened , that we should accept it otherwise the Policy will be cancelled and no money will be refunded.

**. On *.*.**, we replied that we are not accepting their allegation and told them that we may file a case in the Court of Law.


**. On **.*.**, we wrote to Max Bupa that Ms. Isha & I was married in January **** and we have many videos of function in which I can be seen dancing. So there allegation that I was suffering from some knee problem is wrong, but they didn’t replied.




**. On **.*.** , my wife again wrote to Max Bupa that, “You have already rejected my claim on the basis of your inquiry that my husband was suffering from , “Known case of instability of knee , Dec. ****” . Though we had already informed you that now we are going to file a legal case against your Company for the same. But we know that this will cost me time and money both. Your Company will also suffer from the same.
Further, we told them that we will not proceed , if you can satisfy us that I was suffering from , “Known case of instability of knee , Dec. ****”, because at present we have concluded that this is a flimsy excuse for not paying my due claim. So, in the last, we requested that, if they want, they may tell us that how they have concluded that I was suffering from, “Known case of instability of knee , Dec. ****”. If they are able to convince us on this, we will drop the idea of filing the legal case against Max Bupa.
But Max Bupa never replied this mail.
**. So now I have approached you for the help in recovering our genuine claim.

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