Respected Sir/Mam, Myself Jagdish having Group Insurance policy in “United India Insurance company Limited” Through TPA : Paramount Health Services. Policy No : 120200/28/14/P1/05921801 I requested claim for surgery of “Fistula with Perianal Abscess” with below mentioned claim detail. Claim Information : FIR : 2719657 FIR Date : 04/03/2015 But Insurance Company/TPA has rejected claim by Giving reason “Physician does not fulfilled critaria”. Find below detailed reason provided by TPA. Rejection Reason : Present claim is of 32 years old male patient, who was hospitalized for Fistula With Perianl Abs Cess // Ayurvedic Ksharsutra Treatment. As per submitted documents it is evident that that, patient taken treatment by (BAMS) physician. As per definition of MEDICAL PRACTITIONER means a person who holds a degree/diploma of a recognized institution and is registered by Medical Council of respective State of India.
The term Medical Practitioner would include Physician, Specialist and Surgeon. Hence, the physician does not fulfilled the said criteria. So, the claim is declined. Dr. K.B. Shah is a Registered practitioner doing practice more than 30 year & done same kind of surgery many time. Also surgery was done by two physician. But TPA rejected my claim. Specific surgeries can be done by some physician only. In my case “Ayurvedik Ksharsutra tretment” I request you to, kindly look in the matter and do needful to approve my claim.
Email Id: jagdishsavani123@gmail.com