| Address: Ratnagiri, Maharashtra, 410505 |
Subject: refused my patient's mediclaim by starhealth mediclaim insurance company.
Respected sir
Details given bellow
under the consumer protection act, 1986
Consumdisputes redressal forum at pune -irda and
Ombudsmen
1. particulars of complainant
Name:-ghumatkar hospital, bajarpeth, c/o dr ghumatkar mangesh dattatray, near vaishali medical, bajarpeth tal khed dist:-pune. Maharashtra 410505.
Contact no. Mobile number:-[protected], [protected]
Email [protected]@live.in, [protected]@outlook.com
2 particulars of the opposite party
Mrs. Sushama dhumal
Head - zonal underwriting
Pune zonal office
Star health & allied insurance co. Ltd.
2nd floor, venkatesh villa,
Ghole road, shivaji nagar.
Pune-411004
Land line. No.[protected]
Phone numbers:[protected]/[protected]-28288800
Claim intimation number: cli/2018/151128/0502099
Name of the insured-patient : gauri yogesh ghumatkar
Age : 31 years 1 months
Sex: female
Product name : family health optima insurance - 2017
Policy number : p/151128/01/2018/000152
Policy period: from : 29-jun-17 : : to : 28-jun-18
Diagnosis : dengue fever
Date of admission: 12/12/2017 ghumatkar hospital – bajarpeth
Date of discharge:15/12/2017
3. Subject: refused my patient's mediclaim on basis of treatment done in my hospital by me bams doctor .
4. Details of the complaint
Refused my above mentioned patient's mediclaim on basis of treatment done in my hospital by me bams doctor.
Hospital is registered at civil surgeon aundh, pune
. I have all physician, surgeon, pediatrician on call round 'o' clock.in my hospital hospital registation no 391.
Name:-ghumatkar hosoital, bajarpeth, c/o dr ghumatkar mangesh dattatray, bams registation no.: i-41871-a1
My hospital is having registration under nursing home act with civil surgeon pune. Over all this. I have mbbs md (Physician), pediatrician mbbs dch, gynecologist also. By law i have authority to right allopathic medicine in maharashtra about this, i have provided all necessary document. This claim is not my first claim with starhealth mediclaim insurance company, all claims except 3 privious claims are setteled well with same prescription and investigations reports with mý letterhead and registration number and previous 3 rejected claims are also refused to pay due to same reason
. So this is mental harracement and make great loss of my dignity and devaluation of my degree.
5. Related laws and information of rules and regulation made by maharashtra government
My colleague have given application on 16/02/2018 to drug administration authority of pune , maharashtra under right to information act (Rti) 2005, section 6 (1) regarding authority of bams doctors to use allopathic medicines . drug administration department replied me that this official information comes under control of maharashtra council of indian medicine (Mcim), mumbai, maharashtra. Hence drug administration department handed over my rti application to mcim, mumbai under rti act 2005, section 6 (3). Mcim replied me regarding authority of bams doctors to use allopathic medicines. i want to highlight some points regarding above subject by reference with information given by official government authority. (1) . As per circular declared by mcim on 25/01/2017 reference mcim / 1701374 / 2017 bams doctors which one have registered in a , b and a -1 register of mcim have legal authority to use allopathic medicines. (2). above bams doctors have legal authority to issue any type of medical certificate and this certificate is valid for all government, semi - government and private official purposes. (3). As per circular dated 25/01/2017 by mcim, bams doctors are also labelled as qualified medical practitioners hence as per bombay nursing home act 1949 they have legal authority to take hospital registration certificate on his own name. And respective authority is binding to give hospital registration certificate as per bombay nursing home act to bams doctors. i am also attaching copy of some official documents received by government authority. All these documents with you for official /legal purposes.
6. Details of attempts made to get the matter complained of settled and result thereof: (I) personal negotiations also done with starhealth exicative : (Ii) written communication with trader/opposite party also done: i have contacted many time with starhealth mediclaim insurance company refused around 20 times from date of patient's discharged 15/12/2017. But till they refused to pay. I have made email complaint but still same response. I have attached refused claim intimation notes. I made email complaint on their email address with trialling
With jago grahak jago organisation.
7. Compensation claimed for financial loss due to the negligence of the opposite party purpose of consumer complaint against starhealth mediclaim insurance company :
I want reimbursement to my patient around 1 lac and compensation to me making my previous all refused claims under same cause for about 15 lacs with effect from my first claim refused date under same cause, for my mental harassment and making devaluation of my degree in patient's mind. Make me fill inferiority due to this for this 9lacs.
8. the forum/state commission has jurisdiction to entertain the complaint in view of -
This is happening everywhere and this all mediclaim insurance company refusing claim by bams doctor in maharashtra. They will got lesson from this incident. There is big financial loss to middle class people who made claims at this insurance company at village level and their claim got regected due to same reasons. So please help them to get proper service. Claims being made only after treatment at village level when patient got relief, only then he go for claims setteledment. Then consumer should have to got his benefit.
A) section 11 (I)/sec 17 of the consumer protection act (B) the extent of amount involved being rs:15 lacs
(D) the cause of action having accrued at: rajgurunagar
Limitation that the present complaint is being filed within the period prescribed under section 24a of the act. —
prayer
I/we, the above named complaint/complainants respectfully state before the hon'ble forum/commission the complaint as follows:
It is therefore prayed
(I) that opposite party be directed to reimburse the amount with delay of payment of claim to patient rs...1 lacs...
(Ii) complaint may please be compensated to the tune of rs...14lacs. For my privious total mediclaim rejected with same cause and for the mental agony and harassment caused to myself in the due course.
(Iii) cost of litigation may also be awarded suitably.
Place:rajgurunagar
Date :10/09/2018
dr ghumatkar mangesh dattatray
Ghumatkar hospital bajarpeth khed.
I, dr ghumatkar mangesh dattatray s/o - dattatray baban ghumatkar resident of rajgurunagar tal:khed dist pune, 410505 — do solemnly declare and state that the particulars stated above are true to the best of my knowledge and belief and no part thereof is false and nothing material has been concealed therefrom. The annexures are exact copies/translation of their originals. I undertake to pay any sum required for the conducting of test in the laboratory as per the provisions of sec. 13 (1) (D) of the consumer protection act, 1986
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