Reimbursment from blacklisted hospital
5 months ago
I have a corporate MediAssist policy and got my mother operated for spine surgery at one of the blacklisted hospitals which I have to came to know after 10 days of discharge.
The insurance team is clearly denying to accept the claim.
Is there anything that can be done to get the claim accepted
A.Dear Client,
In the given situation, Apart from the settlement of the insurance claim, there is an alternative way to resolve your grievance. All the hospitals, nursing homes and other clinical establishments are issued licenses by the Licensing Authority and the Chief Medical Officer of Health of the District under the Clinical Establishment Act of the respective State. In the said governing Act, there is a chapter for contravention of the provisions of the Act and a penalty to be imposed for the same is furnished which says that Whoever is required by or under this Act to supply any information wilfully withholds such information or gives information which he knows to be false or which he does not believe to be true, shall be liable to a penalty which may extend to......... and Whoever being required by or under this Act to maintain and supply records, reports, registers and other documents wilfully tampers, destroys, falsifies such documents shall be liable to a penalty which may extend to........... Here, in your case, the concerned Hospital has suppressed or wilfully withheld the information of his blacklisting by the Insurer to the insured or policyholder at the time of admission and treatment of the patient and accordingly the concerned Hospital contravenes the provision of penalty mate provision of the Act and liable to face the legal consequences and penalties including the cancellation of license if the aggrieved patient/insured lodged a complaint before the Licensing Authority and the Chief Medical Officer of Health of the District. On receipt of a complaint over contravention or violation of any provision of the Act from the complainant/Insured, the matter is investigated by the Licensing Authority and submits his findings/IR to the Adjudicating Authority and the District Magistrate who is equally empowered under CPC and Cr.Pc for adjudication of the complaint and after hearing both parties and findings of the Licensing Authority passes an order and executable under the relevant law. So, you may after going through the provision of the Clinical Establishment Act of your State, escalate your grievance/complaint against the concerned Hospital before this Forum/Authority to get back your claim amount repudiated by the Insurance Company. This forum is almost hassle-free, less time-consuming, and less expensive than other forums to access justice.
In the given situation, Apart from the settlement of the insurance claim, there is an alternative way to resolve your grievance. All the hospitals, nursing homes and other clinical establishments are issued licenses by the Licensing Authority and the Chief Medical Officer of Health of the District under the Clinical Establishment Act of the respective State. In the said governing Act, there is a chapter for contravention of the provisions of the Act and a penalty to be imposed for the same is furnished which says that Whoever is required by or under this Act to supply any information wilfully withholds such information or gives information which he knows to be false or which he does not believe to be true, shall be liable to a penalty which may extend to......... and Whoever being required by or under this Act to maintain and supply records, reports, registers and other documents wilfully tampers, destroys, falsifies such documents shall be liable to a penalty which may extend to........... Here, in your case, the concerned Hospital has suppressed or wilfully withheld the information of his blacklisting by the Insurer to the insured or policyholder at the time of admission and treatment of the patient and accordingly the concerned Hospital contravenes the provision of penalty mate provision of the Act and liable to face the legal consequences and penalties including the cancellation of license if the aggrieved patient/insured lodged a complaint before the Licensing Authority and the Chief Medical Officer of Health of the District. On receipt of a complaint over contravention or violation of any provision of the Act from the complainant/Insured, the matter is investigated by the Licensing Authority and submits his findings/IR to the Adjudicating Authority and the District Magistrate who is equally empowered under CPC and Cr.Pc for adjudication of the complaint and after hearing both parties and findings of the Licensing Authority passes an order and executable under the relevant law. So, you may after going through the provision of the Clinical Establishment Act of your State, escalate your grievance/complaint against the concerned Hospital before this Forum/Authority to get back your claim amount repudiated by the Insurance Company. This forum is almost hassle-free, less time-consuming, and less expensive than other forums to access justice.
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A.Dear Client,
Our legal team needs to thoroughly review the terms and conditions of your corporate MediAssist policy as insurance policies can vary. We can further provide any legal advice only after going through the said policy.
Our legal team needs to thoroughly review the terms and conditions of your corporate MediAssist policy as insurance policies can vary. We can further provide any legal advice only after going through the said policy.
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