[Resolved]  Raksha Health Insurance TPA — Claim put on hold due to requirement of documents

Address: Faridabad, Haryana

Claim no: [protected]
My mother, Savita Chopra, MemberID: SBIG[protected]SBIDEL
Policy No:[protected]-01, was admitted to Fortis Hospital Shalimar bagh on 28th May - 30th May and had to get angioplasty done.

This was supposed to be a cashless experience but Fortis informed us that the contract with raksha TPA has expired and the amount needs to be paid entirely by us. We had no intimation from Raksha TPA about this. Due to this, we paid the entire amount and filed the claim.

The claim has now been put on hold as certain documents are needed:
1 Kindly provide Break up of Rs 254700 /- charged on account of PACKAGE dated 28/05/2021
We have checked with Fortis and they have mentioned that they do not provide a package breakup. The same is mentioned on their estimate form. This was ideally supposed to be a cashless hospitalization but Fortis informed us on the 28th May that their contract with Raksha TPA has been revised and they cannot allow a cashless hospitalization. Due to this, we were forced to pay the money from our own pocket. There is no way to arrange for the breakup. Fortis is on the panel of Raksha TPA, then they must know this already.

2 Kindly Provide Sticker for Stent used in the surgery.
All the surgery related physical boxes (stents and others) have already been sent.

3 Kindly provide Self Attested Xerox copy of Photo Identity Proof for the Patient : (Aadhar Card /Passport/ PAN card/ Voter Identity Card/ Driving License/Letter from Recognized Public Authority duly affixed with photo).
We will send the same. The requirement for this was nowhere mentioned on the downloaded Raksha TPA claim form.

4 Kindly provide Original Pre-numbered, Preprinted duly signed and stamped Receipt against the Final Hospital Bill
We have checked with Fortis. The inpatient summary bill of Fortis clearly mentions the amount paid by the patient Rs 3, 35, 346. Fortis does not provide any other receipt than this. Then why is a separate receipt needed.

We have been told that without the receipt and package breakup the claim cannot be processed further as Raksha does not work according to Fortis. At first, it is an issue with Raksha TPA that their contract with fortis was terminated. It is due to this a cashless experience turned into a claim settlement. How is it the fault of the patient?

Is this a way to cheat senior citizens of their hard earned money.

Please look into this matter and process this claim forward without the need of any additional receipt and package breakups. Reach out to me on [protected]. I am Rajiv Chopra, the son of Mrs. Savita Chopra.
Was this information helpful?
No (0)
Yes (3)
Aug 10, 2021
Complaint marked as Resolved 
After a long communication, follow up not just with raksha TPA but with Fortis as well, i was able to provide all documents. I believe raksha tpa also followed up with fortis as their contract terms and conditions had changed. I wish the claim process especially for cash hospitalization is simplified for the end consumer and the hospitals and tpa company can provide clear instructions on what docs will be needed to settle the claim. Keeping your customers in dark is not a good idea. Would like to thanks Ms Shweta Singh from raksha for her efforts and helping out with this claim settlement. For now, the claim is settled but i wish the experience was more hassle free considering senior citizens are involved and they cannot around with ease to collect docs from the hospital that they even do not know about.
Raksha Health Insurance TPA customer support has been notified about the posted complaint.
 
Add a Comment

Post your Comment

    I want to submit Complaint Positive Review Neutral Comment
    code
    By clicking Submit you agree to our Terms of Use
    Submit
    Raksha Health Insurance TPA
    customer care contacts
    Customer satisfaction rating Customer satisfaction rating is a complex algorithm that helps our users determine how good a company is at responding and resolving complaints by granting from 1 to 5 stars for each complaint and then ultimately combining them all for an overall score.
    Read more
    15%
    Complaints
    235
    Pending
    0
    Resolved
    36
    Raksha Health Insurance TPA Phone
    +91 12 9428 9999 [Faridabad]
    +91 22 6787 6666 [Mumbai]
    +91 80 4283 9999 [Bangalore]
    Raksha Health Insurance TPA Address
    India
    View all Raksha Health Insurance TPA contact information