Details of the ongoing saga of reimbursement claim with Apollo Munich health insurance in India
I have been a customer of Apollo Munich health insurance for the past 5 years. In June 2017, I filed my first reimbursement claim after I was admitted to a hospital from June 10, 2017 until June 15, 2017. My claim was rejected on 30 2017 for the first time stating that the need for hospitalisation has not been established.
The claim number that was provided was 575112
Since then, I have made 12 phone calls, sent several emails to customerservice with the documents and submitted the documents to their local office multiple times only to get an email from Apollo Munich asking me for more medical records for the illnesses that I'd never had or rejecting my claim stating that I was only taking oral medications in the hospital . As evidence that I suffered from the illness that they claim I have suffered from, they attached the medical records of some other person was 65 years old and has got completely different medical condition. As evidence that I have been only taking oral medication the hospital they keep on pointing out the oral medications that were prescribed to me but forget about IV medications that were given despite submitting prescriptions, pharmacy bills and doctor's note as proof.
Every time I call customer service they mechanically repeat whatever is stated in the most recent communication from Apollo Munich to me and asking me for more medical records. I then have to spend several minutes trying to explain that I have already sent all the medical records in original will Apollo Munich and have also sent it in email.
I continue to suffer from medical conditions which make it difficult for me to remember every little detail about the case. So I'm summarising it in this post.
If some other people also look at it, maybe there will be some ideas on how to rectify the situation and possibly so that it does not recur. I'm completely at my wits and on how to convince a customer relationship officer this on the phone and insists that they are looking at the right medical record and that I suffer from illnesses that are mentioned in the record.
Case history:
I was hospitalised from June 10, 2017 until June 15, 2017.
The name of the hospital is Indresh hospital.
Subsequently I filed a reimbursement claim by submitting the
original documents to Apollo Munich office in Dehradun.
The claim number that was provided was 575112
On June 30, 2017, I received a claim rejection email stating
that the claim was rejected because "the
need for hospitalisation was not established"
On July 2, 2017, I called the customer service to understand
the meaning of the need for hospitalisation. I was told that I need to send a
letter from a doctor explaining why I was hospitalised.
On July 12, 2017, I submitted a letter from the doctor in original
to Apollo Munich office in Dehradun.
On July 18, 2017 I called the customer service yet again to
find out if the letter was received. Until July 18, 2017, I was not sent any
SMS or email acknowledging that the letter was received and so I had to call
again. I was told to wait for at least a week and I was assured that I will
hear from customer service.
On July 22, 2017 I called the customer service for the 3rd
time to find out if the letter was received. I was told that the letter has not
been received and now I need to send a copy via email.
On August 2, 2017 I called the customer service for the 4th
time to find out if the letter was received. I was told to again send the copy
via email. This time I persisted and asked the customer service officer to
raise a query to determine if the letter was received or not. I received an
email acknowledgement for the case. The case ID was 3259401.
On August 2, 2017 I called the customer service for the 5th
time at 3:30 PM to determine if the letter was received. I was sent an
acknowledgement for the letter finally.
On August 4, 2017 I received an email from Apollo Munich
stating that the claim has been rejected because the documentation has not been
received. Further it said that the need of hospitalisation has not been
established which is restating the same
reason despite submitting our doctor's letter and after making 4 phone calls to
customer service over 20 days.
On August 10, 2017, I called the customer service for the 6th
time to understand why the claim has been rejected for the same reason. I was
asked to send an email yet again.
On August 11, 2017 I received an email from customer service
stating that they are reviewing my case.
On August 16, 2017 I called the customer service for the 7th
time to figure out why I never got any response. I was told to wait for a few
more days.
On September 1, 2017 I I called the customer service for the
8th time to understand why I never get any response in the past 20
days. I was told that someone will respond immediately.
On September 2, 2017 I was sent an email from customer
service stating that the reason for rejection was that "I had not provided documents for a medical
condition called cerebral vascular disease. Further, it said that I was a
patient of diabetes and hypertension." I have never had any of the 3 conditions that were mentioned.
On September 7, 2017 I called the customer service for the 9th
time to understand this very puzzling reason. After a lengthy conversation with
the customer service representative where she kept on claiming that I had the
disease that were mentioned in the letter and I must be wrong, I persuaded her
to file a query and ask Apollo Munich to send me the documents from where they
learned that I was a patient of diabetes and hypertension.
On September 8, 2017 I got a call from Apollo Munich again
asking about the entire case. I patiently explained the entire case to him.
On September 9, 2017 I got an email from Apollo Munich
providing me the that the document from where they had inferred that I was a
patient of diabetes, hypertension and cerebral vascular disease.
In the document it
was clearly stated that the name of the subscriber/patient was incorrect. It
was for some 65-year-old patient admitted to Bharat heart Institute in
Dehradun.
So at the end of 12 phone calls, numerous email exchanges and
multiple reviews, it seems that Apollo Munich have been looking at the wrong
record all along. Ironically, every marketing emails from Apollo Munich either
implies or says explicitly that they provide un complicated health services.
Nothing can be farther from truth because in 3 months Apollo Munich was not
able to even access the right record and kept on insisting that the patient was
not providing documents.
Update:
On September 14, 2017 I raised a complaint with the grievances department at Apollo Munich. Email ID is grievances@apollomunichinsurance.com with a cc to customerserviceapollomunichinsurance.com. Note that apart from sending emails there is absolutely no way to contact grievance department. I wonder why they cannot put a customer in touch with the person was deciding their fate.
On September 21, 2017, after a couple of emails with boilerplate text of ironic messages assuring messages assuring "customer delight".I got an email response from Radhakrishna Das Adhikari
Officer -Grievance Management team. Snapshot of 2 different medical papers that I had given them were sent. The good thing is that after almost 2 months of denying that they had received my original set of paper that I had provided them on July 12, 2017, this seemed to have finally found the original set of papers. However, once again they are asking for "all indoor case papers and other treatment records including the first consultation of the ailment". And they again want the original of all these. I had already provided them originals. But since there is no way of them acknowledging what set of papers they have received, they can obviously deny that they got the papers and ask for them again.
Update:
On September 14, 2017 I raised a complaint with the grievances department at Apollo Munich. Email ID is grievances@apollomunichinsurance.com with a cc to customerserviceapollomunichinsurance.com. Note that apart from sending emails there is absolutely no way to contact grievance department. I wonder why they cannot put a customer in touch with the person was deciding their fate.
On September 21, 2017, after a couple of emails with boilerplate text of ironic messages assuring messages assuring "customer delight".I got an email response from Radhakrishna Das Adhikari
Officer -Grievance Management team. Snapshot of 2 different medical papers that I had given them were sent. The good thing is that after almost 2 months of denying that they had received my original set of paper that I had provided them on July 12, 2017, this seemed to have finally found the original set of papers. However, once again they are asking for "all indoor case papers and other treatment records including the first consultation of the ailment". And they again want the original of all these. I had already provided them originals. But since there is no way of them acknowledging what set of papers they have received, they can obviously deny that they got the papers and ask for them again.
On September 21, 2017, I sent them an email response again asking them if they can send me all the papers that they think they have got from me. Instead of me sending them the papers and they again denying that the got them, I thought it would be better if they send a scan of the papers. At least we would know what they have received and then I can provide them any additional information. So far, I cannot think of anything else
On September 28, 2017-Apollo Munich sent a response asking for all the hospital inpatient department papers. They also asked for the first consultation paper which I had already provided and pointed out in phone conversations.
On October 8, 2017-after making multiple visits to the hospital and paying Rs. 500, I was able to obtain the inpatient department papers. I sent to those papers to Apollo Munich grievance email ID. .
On October 16, 2017-Radhakrishna Das Adhikari Officer -Grievance Management Apollo Munich sent a response rejected my claim saying that the need of hospitalisation was not established and that I needed only oral medications. They conveniently forgot that prescriptions, pharmacy bills and our doctor's note had been submitted all indicating that I was administered medication is through IV. I really wonder which person in the same mind would get admitted into a hospital to get oral medications? So I sent them an email with a red circle around each of the entries on the medical document which indicated that I was administered IV medication. I got a response from Tania Piplani stating that they will reply by the end of November 1, 2017.
On November 2, 2017 , I got a call from the grievance department. The told me that that they would connect me to a Dr in the next 3 hours and asked me to be available. Fortunately, the callback in the next half an hour. Finally, the doctor was the 1st person from Apollo Munich who seemed to be reasonable. She said it was not clear to her why I was admitted to the hospital and was taking only oral medication. I again told her that it is clearly written in the medical documents that I was on IV. She asked me to get an explicit certificate from the doctor again mentioning that I indeed needed the IV because I was unable to take the oral medications due to gastrointestinal distress. She also wanted to clarify a remark that another doctor had made on one of the prescriptions. Both the doctors were out on a vacation and finally I was able to submit the certificates from both of the doctors on December 10, 2017.
On December 16, 2017, I finally received an email from Apollo Munich stating that they have reviewed my case and will reimburse the amount.
In summary, after 5 months of continual follow-up, persistence and getting the certificates from various doctors over and over again, I was able to get Apollo Munich to reimburse the amount. Had Apollo Munich made the doctor speak to me once over the phone, we would have avoided unnecessary paperwork and calls to customer service at Apollo Munich which waste their time also.
I hope documentation of this case helps other customers of health insurance in India. If someone from the insurance industry gets to read this content, please consider the fact that pushing back on consumers claim for reimbursement does not help anyone eventually. Maybe in the short term, the insurance company gets to save money, but if it is looking for high growth, it has to improve its service by making the procedure, transparent and reducing unnecessary, time-consuming back-and-forth communication.
On September 28, 2017-Apollo Munich sent a response asking for all the hospital inpatient department papers. They also asked for the first consultation paper which I had already provided and pointed out in phone conversations.
On October 8, 2017-after making multiple visits to the hospital and paying Rs. 500, I was able to obtain the inpatient department papers. I sent to those papers to Apollo Munich grievance email ID. .
On October 16, 2017-Radhakrishna Das Adhikari Officer -Grievance Management Apollo Munich sent a response rejected my claim saying that the need of hospitalisation was not established and that I needed only oral medications. They conveniently forgot that prescriptions, pharmacy bills and our doctor's note had been submitted all indicating that I was administered medication is through IV. I really wonder which person in the same mind would get admitted into a hospital to get oral medications? So I sent them an email with a red circle around each of the entries on the medical document which indicated that I was administered IV medication. I got a response from Tania Piplani stating that they will reply by the end of November 1, 2017.
On November 2, 2017 , I got a call from the grievance department. The told me that that they would connect me to a Dr in the next 3 hours and asked me to be available. Fortunately, the callback in the next half an hour. Finally, the doctor was the 1st person from Apollo Munich who seemed to be reasonable. She said it was not clear to her why I was admitted to the hospital and was taking only oral medication. I again told her that it is clearly written in the medical documents that I was on IV. She asked me to get an explicit certificate from the doctor again mentioning that I indeed needed the IV because I was unable to take the oral medications due to gastrointestinal distress. She also wanted to clarify a remark that another doctor had made on one of the prescriptions. Both the doctors were out on a vacation and finally I was able to submit the certificates from both of the doctors on December 10, 2017.
On December 16, 2017, I finally received an email from Apollo Munich stating that they have reviewed my case and will reimburse the amount.
In summary, after 5 months of continual follow-up, persistence and getting the certificates from various doctors over and over again, I was able to get Apollo Munich to reimburse the amount. Had Apollo Munich made the doctor speak to me once over the phone, we would have avoided unnecessary paperwork and calls to customer service at Apollo Munich which waste their time also.
I hope documentation of this case helps other customers of health insurance in India. If someone from the insurance industry gets to read this content, please consider the fact that pushing back on consumers claim for reimbursement does not help anyone eventually. Maybe in the short term, the insurance company gets to save money, but if it is looking for high growth, it has to improve its service by making the procedure, transparent and reducing unnecessary, time-consuming back-and-forth communication.
Common tactics used by Apollo Munich that I have seen + suggested remedies:
- keep on asking for the case documents over and over again. Since there is no way in the system for the insurance company to acknowledge what papers they have received, they can always deny that they received papers and ask for them again. This could have easily been prevented if there is a system where the company automatically shares the document it has received through its website or by sending an email to the customer.
- The claim department and the grievances department cannot be reached by any other way except email. From my past experiences with various companies, the insurance sector seems to be the only one way that you cannot meet a person who has knowledge of the case and at least some level of authority in decision-making face-to-face or at least on phone. They can easily set up a web tracking system where they can show how the case is moving from one person to another within their organisation and also at least provide some sort of contact information.
- There is absolutely no penalty for the company for any kind of delay. While they are required the customer to provide them the documents within 15 days, it is not binding on them to respond within 15 days in any way. If they do not respond, they will merely assure you once again that they are going to respond in the next 15 days. Remedy: while this is a common consumer issue across different sectors, it is particularly difficult in the health sector where the consumer may not have enough energy/resources to deal with the delay. There has to be an outside limit after which the case should get automatically escalated to IrDA regardless of what is the status of the case. Or at least, the company should be required to publish the total number of cases that they have received, the cases that are pending, and the cases where the claim was closed with payment and without payment.
Please approach IRDA, the regulator in this case as the company is not listening to your case. You can also approach consumer court in this case.
ReplyDeleteBut first approach IRDA
Thank you for your response. Yes I am in the process of approaching the ombudsman as recommended by IrDA. However, as I have learned from another individual's experience, dealing with IrDA or consumer court requires physical presence multiple times, which is not possible in my case due to my medical condition.
DeleteThe main problem is that there is no penalty for an insurance company to delay its decision on the claim. At the end of it all, even if the process extends for several years, all they are liable to pay is the claim amount. At least that is what I know. So there is no incentive for to pay the claim amount earlier in the process.
I can also not find any regulatory requirement to make the insurance companies provide audited figures on how many claims they have received versus how many were fraudulent and how many were denied. If that was made mandatory, perhaps the insurance companies will work towards settling claims otherwise they will lose customers.