Claim Deduction - TPA MDINDIA

The Assistt Secretary,

LIC OF INDIA, CO,

(MUMBAI. 

MDI has sent to me CLAIM DEDUCTION  SHEET with a copy to you amongst others and the details of payment Rs 59,472/- sent to you by RTGS on 08-04-2020. Hope you have received it. 

Now I have to bring to your notice to enable you to take up the matter with New India and MDI under advice to me at an early date :-

(1).  My wife is aged 84 years and bed ridden since last 4-5 years, unable even to stand or sit out of her own what to say to go to the toilet attached to the room. 

(2)   From the year 2015, she has been in Fortis Hospital for more than 5 times and for a major period in ICU fighting for life and death. Lastly, she has been discharged on being stable at my request on 21-12-2019 and her last Discharge Summary running into 9 pages describes multiple ailments she has been suffering from and the present Claim is for a period of two months of post- hospitalisation treatment. 

(3).   The post- hospitalisation treatment is nothing else except the extension of hospital treatment, but at home resulting into substantial reduction of expenses towards treatment. The main point for consideration here is that whatever items have been used

 in the hospital and the expenses have been allowed, such items and expenses should also be allowed if used during this period and such expenses should not be treated as non- medical expenses for a 84 year aged bed- ridden patient.

(4).   This time I submitted a claim of post-hospitalisation for Rs 1,59,873/- including Physio exercises. MDI allowed claim of only Rs 89,057/- and disallowed claim of Rs 70,826/-. There are two glaring points for your knowledge.  Firstly, they allowed Rs 30,000/- towards Physio exercises on the ground that our Scheme permitted only a maximum sum of Rs 30,000/- . Secondly, they disallowed a sum of about Rs 37,000/- and odd at the time of discharge from hospital on 21-12-2019 on the ground of non- medical items such as diapers, wipes, toilet rolls, under sheet etc ie items required to clean the bed ridden patient. I sent a Representation through you and they have now on 08-04-2020 allowed another sum of Rs 59,472/- and this amount included the sum of Rs 10,000/- wrongly disallowed earlier towards Physio exercises and most of the items towards cleaning the patient. It is clear that there is no consistency in their decisions and that they are unaware that our Scheme permitted upto a. Sum of Rs 40,000/- towards Physio exercises  and allow  deducted amount in piece-meal when representations made again and again. 

(5).  Now on 08-04-2020 they have sent CLAIM DEDUCTION SHEET wherein the total of all the items is given is Rs 64,251/-whereas deducted amount is 70,826/-, thus this sheet is silent on the difference is Rs 6,575/-. They have not given details and reason of  this deducted amount of Rs 6,575/-. The reason is best known to them and suppression of these facts is not understandable. 

(6).  Out of the total items of this Sheet for Rs 64,251/-, they have given details of 5 bills with reason as under:-

          Bill No.                   Date.                       Amount.                  Reason

           4326.                05-01-2020.              2,998=00.              Diaper - non medical

        147448.               25-01-2020.              1,386=00.              ————-do————-

            4480.               17-01-2020.               1,059=00.               Urometer

          21415.                28-12-2019.                 349=00.            Bed wipes- non medical

                                                                                                             Duplicate bill

           21753.               02-01-2020.                998=00.            Duplicate bill

        184803.               07-12-2019.                 410=00.            Original bill not signed

                                                                                                              and stamped

                                                                         TOTAL Rs 6,202/-

(a).  Bills 4326, 147448 and 21415 for a sum of Rs 4,733/- have been disallowed as the diapers and bed wipes are non medical items.  For a bed ridden patient for a very long period to clean the motion, a number of items such as masks, gloves, underpad, tissue paper, wipes, diapers are required. Out of all these items only diaper and wipes are non medical items and whether the patient will be allowed to pass motion on bed sheet of the bed and not cleaned because diaper and wipes are non medical items. Then in which case, these items will be medical items. Moreover, all these items have been allowed by MDI earlier on my representation after discharge on 21-12-2019. This explanation has been given by me in the original claim dt 24-02-2020 and subsequent representation and still these have been disallowed. Further Bill 21415 and 21753 are from Amazon which bears remarks as DUPLICATE FOR TRANSPORTER. I received these bills only with the items and  these bills contain our address, dealers address who is from Calcutta, Pan number, GST number, Order number, Invoice number.  These could have been duplicate, had I submitted such a bill and already claimed the amount. Inspite of all the details and for a small amount of Rs 349/- and Rs 998/- they have rejected the claim. Do they mean I should go to Calcutta ie more than 2000kms from Gurgaon to get  these bills corrected. Had I claimed this amount earlier, their rejection would have hold water. Suppose sometimes in such difficult times original bill is lost or misplaced, the only option would be to obtain a Duplicate copy and in the case of loss of bill legally also submission of a duplicate from the original issuer is perfectly admissible, whereas in the instant case the remark is for the transporter because the supplier is at Calcutta. If still there is any doubt, MDI could have just checked up the details by a mere call to Amazon or by sending a message to satisfy themselves. 

(b).  Bill number 4480 does not pertain to any instrument known as UROMETER.  She is bed ridden for a long period, unable to go to toilet. Therefore, catheter is inserted for urine from the day she is bed ridden. With catheter urine bag is attached and urine beg of 2000ml with measuring plastic bottle is known as UROMETER URINE BAG. It is known even to a lay man that this catheter with urine beg has to be changed after every 3-4 weeks to avoid infection in kidney. From the very beginning this urometer urine beg is being used and MDI has always reimbursed the amount. This type of urine beg is used from first hospital admission and the purpose is to measure the urine output to enable the doctor to monitor the functioning of kidneys and to know any adverse effect of any medicine from various medicines being administered to her from time to time.   MDI has even allowed Nurse charges Rs 800/- to change the catheter. It is not known why this time this amount of Rs 1,059/- for catheter and urometer urine bag has been disallowed. I may also clarify this catheter and even urometer  urine bag is one time useable only.

(c).  Bill 184803 for Rs 410/- is from Fortis Hospital itself and computer generated, which contains our address with patient name, doctors name, name Mr Harish who dispensed the medicine, date and time of bill. If they had any doubt, they could have obtained confirmation from the hospital. It is a paradox that MDI has been accepting all the digital msgs from the hospital, but rejected the bill issued by the same hospital digitally. I am exchanging msgs with you as well as MDI digitally, are any such msgs ever signed and are these not acted upon.

(7).  From the above discussion, you would please observe that the claims are being settled by MDI in piece-meal on receipt of representations and the irony is that those items are being disallowed, which have already been allowed earlier and, thus, there is no consistency in their decisions. Even the provisions of the Scheme are not properly looked into, which may be exemplified from the fact that a sum of Rs 10,000/- was disallowed for Physio exercises on the ground that the Scheme permitted a maximum sum of Rs 30,000/- as against Rs 40,000/-.Computer generated bill even of the Hospital has been rejected because not bearing signatures.  On line bills have been rejected on the ground of not bearing signatures and stamp, though they contained all material details, as mentioned by me hereinabove. As far as our Scheme or any other written matter can never be perfect to take care of each and every future situation. Though the bills need to be processed within the parameters of the Scheme, the discharge summary should be carefully gone through to have an overall view of the condition of the patient and the treatment given and earlier decisions and focus should not be to reject a claim on mere technicalities, but try  to be practical to find a way to settle it, as the Scheme is a contributory welfare Scheme. If some of the items can not be approved in the first instance, claim for those items should not be outright rejected, but should be kept on hold till satisfactory explanation is received.

   In these circumstances, I would request you not to simply forward this representation to MDI, but to bring it with my earlier representations to the knowledge of Sr.D.M, New India and some senior official of MDI to look into the points raised by me in all the representations to tone up the bills processing machinery to avoid all this type of not only wastage of time at each level but the harassment of the beneficiaries.

Hope to hear from your end at the earliest.

Thanking you,

S R AGARWAL

Retd Secretarey

LIC, CO, Mumbai

S R 207257

Mob. 8527571711