TPA called Raksha TPA has refused a genuine claim for my mother’s surgery by giving a silly technical reason that the claim needs to be submitted to them within 7 days of discharge from the hospital (our papers reached them on 8th day as per the acknowledgment though they claim to have recd. on 10th day. Their exclusion clause was never highlighted , mentioned in the small( 2”x 3”) pocket guide in a small print. I have communicated with United India Insurance Co.but not much positive response from them so far
Dr.Abhijit Kher
9821043911
info@niramaymothercare.com
Raksha TPA/United India Insurance Company
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June 23rd, 2010 on 11:35 pm
Dear Dr. Abhijit,
The Insurance Company or TPA has rejected your claim, as per the Terms and Conditions mentioned in the Policy Wordings which form part of a standard mediclaim policy (including those of United India Insurance)
The Terms and Conditions require each claimant to
1. Intimate the Claim within 1 day.
2. Submit Claims Documents within 7 days.
Earlier, Health Insurance Companies/TPAs used to leniently allow 30 days window to submit claims. With regular losses being faced by these companies, they have resorted to enforcing this clause in the policy.
We can advise you further, which may help you put up a case with the Insurance co. and get a relief.
1. Provide us with the exact dates of discharge, submission of documents (date of acknowledgment) by Insurance Company/TPA.
2. Scanned copy of the letter received by TPA/Insurance Co.
3. Information regarding any written communication you have made with Insurance Co. or TPA, subsequent to their denial of the Claim.
You can write to us in the comments section below. You can also send us the documents at ask (at) medimanage.com
Note: We dont charge for this kind of advisory over email or web.