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'HELP! Rs 3.48L insurance claim settled at Rs 51k'

By SANJIB JHA
November 24, 2022 08:53 IST
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Do you have auto or health insurance/mediclaim queries?

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Sanjib Jha, CEO, Coverfox Insurance Broking (external link) will answer your health and auto insurance queries.

Please mail your queries to getahead@rediff.co.in with the subject line 'Ask Sanjib' and he will answer all your health insurance queries.

 

K D Agarwal: I have a Mediclaim insurance policy (senior citizens) from National Insurance co Ltd. My wife was operated for Knee replacement surgery. Against the claim of Rs 3.48 lakh, the claim was passed for 51000/- only. I wrote to the Insurance co and wanted to know the reason but no answer. I seek your help and guidance.

Sanjib Jha: Hi KD, hope your wife has recovered. To answer your query, I advise you to check your policy document again. There are many health insurance policies that have capping/limitations on the list of ailments. You can find the same in the policy documents or policy wording.

I suggest you approach your insurance company and inquire about the same and if you still fail to get a response from them then you can approach insurer ombudsman for this issue.

Gora Lal Gargi: I was customer of Oriental Bank of Commerce. Being a customer of Oriental Bank of Commerce, Oriental Insurance Company provided Group Health Insurance Policy and inception date was 04-05-2015. My policy with them continued till 03-05-2021 without any break. Because Oriental Bank of Commerce merged with Punjab National Bank, Oriental Insurance Company discontinued that policy from 03-05-2021 onward.

Being a customer of Punjab National Bank, I approached them, and they migrated my Group Health Insurance Policy of Oriental Insurance Company to Star Group Health Insurance Policy for customers of Punjab National Bank from 04-05-2021 to 03-05-2022. 

As All my policy periods were continued from 04-05-2015 till 03-05-2021 with Oriental Insurance Company, Star Health Insurance given me the benefit of pre-existing disease waiting periods being waived because of continuity (They mentioned it in Policy Document too).

They reimbursed my 1st claim of 15 July to 22 July 2021 (Non Empaneled Hospital) and Cashless claim of 16 December to 19/12/2021 but denied reimbursement of 19/12/2021 to 26/12/2021 with the excuse of pre-existing disease even I directly shifted from cashless hospital to non-Empaneled Hospital for same problem because Empaneled hospital having been less facilities. 

Here I want to address that I was discharged from Cashless Hospital, on request, to get treated in Higher Hospital and treatment was in continuation of previous cashless hospital to new hospital.

So, sir, please guide me accordingly as my correspondence with them is not fruitful.

Sanjib Jha: Hi Gora Lal Gargi, to solve your query I will need more information. Firstly, please do check if your sum insured value was exhausted in the first claim.

If yes, then check the policy document to know if your insurer provides claim for same person, same illness on the second claim i.e. restoration benefits.

In case, the sum insured is not exhausted then you are eligible for the second claim and I advise you to write to ombudsmen about your issue. You need to email them at complaints@irdai.gov.in (external link) with your query along with all the documents of your case. 

Mittal Shah: I have been operated for Wilson's disease for my liver. I got admitted in Nov 21 and got discharged in Dec 21. My insurance company paid all expenses up to Sum insured and the same got exhausted in Dec 21 and then I renewed the policy in Jan 22. As per my Policy I am eligible for claiming 60-days medical expenses post hospitalisation and submitting the bills but the TPA is repudiated it with remarks that not eligible as the treatment done in 2021 and bills for 2022 are not admissible though the insurance company is same.

Please help to know how do I tackle it and is there any alternate possibility.

Sanjib Jha: Hi Mittal, as far as I have understood your query, your sum insured exhausted during the hospitalisation process. Once the sum insured is exhausted, you cannot claim post hospitalisation bills.  

However, if your sum insured was not completely exhausted, you would have got the claim for post hospitalisation even if the bills were dated in Jan 2022, i.e. within 60 days of discharge.

You can find more of Sanjib Jha's answers here.


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