Simplest Guide for Health Insurance in India

Hello,

I was about to go through a laproscopy for endometriosis. The reason of the surgery was chronic pain in lower abdomen during menstrual cycles.
Earlier I was taking ayurvedic and homeopathy treatment as pain killers like meftal, meftal spas etc were in-effective for me.
In month of Feb-March 2010, I visited gynecologist in Deenanath Mangeshkar hospital and she advised me to go through laproscopy. For some personal reasons, I started the treatment with some other gynecologist from same department.
During month of June 2010, the endometriotic ceast size grew to 6 cm and it was urgent to do the surgery.
So I applied for my company’s insurance submitting all the required papers for cashless facility.
On the day when my surgery was going on, company/TPA sent rejection letter.
They gave the reason that they do not see any reason for admission.
I was admitted to hospital for 2 days and had 4 stitches. My surgery lasted for 2.5 hours and still the company says that there no reason for admission to the hospital.
Are there any doctors working in TPA? Do they really know anything about medical field?
We had to manage the money and pay the hospital bills of rs. 56000/-

I had similar incidence for my father’s treatment as well. He had hardaz disease, which affects your vision completely. By God’s grace, it was detected in earlier stage and he started with the treatment and recovering from it now.
He had to go through some expensive investigations and later on treatment costing around Rs.8000/-
He is retired from the service so Rs.8000/- is also a good enough amount for him.
He is also covered under my health insurance. So I claimed his medical expenses to same Oriental health insurance.
After 2 weeks, they rejected the claim saying “we cannot see any treatment given under admission. It looks to be mainly for investigation. All the medication is given after admission, which can be taken at home.”
I talked to my office agent and resubmitted the claim. But it got rejected again.

If in case of emergency, the insurance company is going to take us down then what is the use of paying so much premium every year?
We take help of medical insurance so our tension during hospitalization is only our dear and near one’s health and not money. But looks like these companies just find their way for not giving money, even though we pay premium regularly.

Having an efficient agent/broker who understands health and health insurance would be key in getting valid and correct claims documents to reach your TPA in time.

Call the TPA (Third Party Administrator) immediately you know about the hospitalisation schedule and within 24 hours of admission to hospital if it’s an emergency hospitalisation.

• Also write a mail or send a fax to the TPA or the health insurance company informing them about the hospitalization within the aforesaid time frame (this is because many health insurance companies recognize written communication only. You will also have a record of having provided the intimation.)
• The TPA or Health Insurance Company will provide you the intimation number through mail or sms but if they don’t, you must call them up and ask for the claim intimation number. This number is important for you to establish that your claim is duly intimated and is a helpful identity later in getting your claim processed and settled, so make sure you receive it.

For Documents Submission:

• Fill in the claim form provided in the company website or available with your Agent or Broker with details like your complete name, age, gender,  date of hospitalization, date of discharge, name of the hospital/nursing home, name of the medical practitioner, etc.
• Attach all the necessary claim documents (mentioned in policy wordings in the Claims Notice section) with the claim form and send it to the TPA or the Health insurance Company as mentioned in the policy within 7 days of from date of discharge, and get the same duly acknowledged with the time and date of receipt.

To read more see Health Insurance Claim Documents Submitted beyond 7 days rejected!

PA E MEDITEK TPA SERVICE PVT LTD

CLAIM NO 835603

NAME CHAUHAN MANOJ SHANTILAL

WE HAVE ALL READY ALL PAPERS ARE SUBMITTED BUT THE TPA WILL NOT PAY THE CLAIN LAST 6 MONTHS SO SIR PLEASE JUSTICE ME AND THANKING YOU

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

In an emergency hospitalization, the important thing is to get the patient treatment at the earliest. You need to start the procedure for cashless facility within 24 hours of hospitalization.

• Show your health insurance card and fill in the pre-authorization form.
• The insurance desk in the hospital will fast track the process for your cashless process but in case you cannot wait for the approval, you can pay the deposit if demanded by the hospital and start the treatment and reimburse the expense later on.
• Generally the time to taken to process an emergency case is 6 hours. You need to follow up with the TPA to know the status of the request.

To know more see Cashless Hospitalization

In a planned hospitalization, you have a recommendation for hospitalization by your doctor and have time to decide which hospital to go to. You have to complete the formalities at least 3-4 days before you are hospitalized.

• Take a look at the list of network hospitals  provided while buying the Health Insurance policy or call the toll free number on your health insurance card and select the network hospital nearest and most convenient to you.
• Show your health insurance card and fill up the first part that is to be filled by the patient of the ‘pre-authorization’ form that you get in the insurance desk of the network hospital or which you can download from website of your TPA.
• Provide the filled form on the insurance desk of your hospital, the person at the insurance desk will verify its completeness and then fax it to the TPA.
• The TPA will then process the form and either approve or reject the request.
• If your form is approved, the TPA will send the authorization letter with an approved amount for the treatment.

To know more see Cashless Hospitalization

Health insurance companies make tie-ups with hospitals after negotiating their rates and checking their quality. These hospitals are called as Network Hospitals; Cashless service is available only in these hospitals. To know which hospitals are in your health insurance provider’s network, check the name of your TPA in the policy and visit its website or call their toll free number.

TPA or Third Party Administrators are the representatives of the health insurance companies who are responsible for settling the claims both reimbursement claims as well as cashless claims. It is the TPAs who have to approve your request for cashless and provide the service.

Pre authorization form is the form that you get at the insurance desk in the hospital or in the website of the TPA, after being duly filled by the patient and the hospital’s representatives, it is sent to the TPA which decides to approve or reject the claim.

To know more see Cashless Hospitalization

When it comes to finding the right insurance agent, many would agree that they have to have your best interest at heart. Unfortunately, it will take time for people to find the right insurance agent that caters to their needs. However, here are some tips for you:

• Knowledge: Again, a good insurance agent should also be a knowledgeable one. He must know everything about the particular policy and must also be knowledgeable about matters of health. For instance, if you want to undergo cosmetic dentistry, your agent should be able to tell you if or not it is covered, and if not, then why. He should also know as to how the particular policy that is suited to you, differs from the same kind of policy offered by a competitor health insurance company.

• Helpful: A good insurance agent is helpful, in the sense that he can help you process claims, get your papers in order, and if it may not be possible for you to contact the TPA, he can contact on your behalf and get your claims processed.

• Accessibility: Very importantly your agent must be accessible anytime you need his help.

To know more see Good Health Insurance agent

To,
Honorable Consumer Court

I, Asad Husain S/o Late Zahid Husain, R/o Yamuna Vihar, Delhi-110053, I hereby serve complaint upon the following reason:
1. That the representative of (RGI) Reliance General Insurance (Mr. Rajkumar) visited my premises and requested me to avail RGI mediclaim policy. I acceded his request and accordingly opted for a mediclaim policy for the period 01.04.2008 to 31.03.2009 vide policy bearing no. 282550051984 dated 02.04.2008.
2. That on 24.02.2009 at around 8:45 pm, I was returning to my Home from my office situated at Faridabad with my colleague (Virti Shrivastava) by my bike make Pulsar bearing Regn. No. DL7 ST 8866, while reached to Okhla Mor I suddenly lost my control on my bike and fell down on the road due to the bad conditions (Pits and holes) on the roads which were not seen as there was water logging on the road.
3. That immediately thereafter, I and my colleague was taken to nearby Hospital (Holy Family Hospital) by some passersby whereupon after conducting my tests/ checkups the doctors found that my left arm is broken and steel plate will have to be fix by way of operation and thereafter they admitted me for treatment.
4. That the officials of Holy family Hospital asked my brother (Amjad Husain) to deposit money for my treatment who had reached to the hospital as he was aware that I have above mentioned policy therefore, he presented my mediclaim card for cash less treatment but the officials of the hospitals refused to accept the same stating that that we are not in the panel of this company. Thereafter, my brother contacted to RGI’s authorized TPA’s (E-Meditek Solutions) customer care.
5. That TPA’s customer care executive advised my brother to take the treatment in the same hospital and asked him to submit all the bills of treatment to TPA after my clients discharge. Customer Care Executive also assured that all the bills will be reimburse by RGI and entire claim will be settled by RGI. Accordingly, he deposited the money with the hospital.
6. That on 25.02.2009 one Policeman visited the hospital and recorded my statement and thereafter I was operated and discharged on 27.02.2009 from the hospital.
7. That after some time as I was on bed in ridden condition, on 17.03.2009 I submitted all documents/bills to TPA. After one week TPA demanded me to submit some more documents to settle the claim and accordingly I submitted the same documents on 27.03.2009 as per TPA’s requirements.
8. That thereafter I contacted TPA as well RGI and inquire about the status of my claim, to the utter shock and surprise of me, I was replied by TPA’s Customer Care Executive that claim was rejected. When I asked about the reason of rejection he disconnected my phone.
9. That on 13.04.2009, I sent an email and repeated my request with regard to the claim. In response to my email I received an email on the same day sent by RGI’s customer service team.
10. That on 14.04.2009 I again sent an email to Ms. Shubhra Tyagi/Mr. Brijesh Sareen and again requested to settle my claim. In response of the same TPA issued a Repudiation Letter dated 14.04.2009 thereby stating that as per discharge summary, patient has been admitted in the hospital on 24.02.2009 but certified copy of from the police station states that patient had the accident on 25.02.2009. Thus, there is a gross variation in the narration of accident. Hence, the claim cannot be settled. The rejection of the claim is shows mollified on your part and the same is apparent with the fact that I had submitted the certified copy of DD Entry bearing no. 25 A dated 24.02.2009. Mere perusal of the DD No. 25 A transpires that the information with regard to the accident is received in the Police Station at 9.00 P.M. on 24.02.2009. However, my statement was recorded by the police on 25.02.2009 vide DD No. 688 dated 25.02.2009.
11. That TPA mollified and illegally rejected my claim by way of manipulating the facts that the accident was occurred on 25.02.2009 and treated the date of recording of statement as date of accident.
12. I kept on writing various email in this regard and also visited personally TPA office, Gurgaon. On 04.05.2009 I received an email sent by Shubhra Tyagi, from RGI Health Claim Department thereby informing that the discrepancy has been waived off under the said claim and TPA has been recommended to process the claim on merits of the same.
13. That I kept on waiting for the response to TPA’s side finally on May 13, I sent another email to Shubhra Tyagi to which I was replied that my claim has been rejected and repeated the same thing that as per discharge summary, patient has been admitted in the hospital on 24.02.2009 but certified copy of from the police station states that patient had the accident on 25.02.2009. Thus, there is a gross variation in the narration of accident. I called many times to Shubhra Tyagi but she was not picking my call. Then on 14.05.2009 I sent another email to said Shubhra Tyagi and protested against the rejection of claim.
14. That I received another letter dated June 16, 2009 for clarification with regard to the contradictions in the discharge summary/MLC of the hospital and certified copy of Police reports. In response of the same I have already clarified that I have not told the reason of accident to the hospitals officials as they have written the reason of accident that my bike was hit by a car. I don’t know who has given this information to the hospital’s official as I was not proper state of mind at the time when I was brought to the hospital. The and the statement of mine was recorded on 25.02.2009 and it was the Police to whom I stated the reason not the Hospital Officials and even on the MLC also there was no where written that the reason of the accident was told by me to the Hospital officials. In the MLC itself it is written that “ALLEGED” to hit by a car. That since the information to the Hospital officials regarding reason of accident was not confirmed and was wrong. Therefore, I should not be suffering for the mistake/fault committed by the Hospital people.
15. That RGI have itself stated vide Shubhra Tyagi’s email that discrepancies with regard to the claim have been waived off and therefore, no question should be arise for rejection of my claim by way of taking the same ground again.
16. That due to RGI and TPA’s above said acts and activities I am suffering not only in monetary point of view but mental harassment also.

Please, you are requested to take an action against RGI and TPA regarding my claim on base of above said statement. Please settle my claim because I am very frustrated.

Thanking you

Sincerely yours

Asad Husain
(Claimant)

I AND MY WIFE ARE COVERED FOR RS. 1 LAC UNDER TAILOR MADE GROUP FLOATER MEDI CLAIM POLICY SINCE 12-04-2006 TO 11-04-2009.NO CLAIM IS LODGED BY ME DURING THE ABOVE PERIOD. NOW I HAVE SWITCHED OVER TO MEDI CLAIM POLICY OFFERED BY PSU BANK WITH LOWER PREMIUMS AND HIGH RISK COVERAGE. NOW I WANT NO CLAIM CERTIFICATE FROM MY OLD TPA WHICH IS DENIED. TO HAVE COVERAGE FOR ALL DISEASES I NEED THIS CERTIFICATE.
KINDLY LOOK IN TO THE MATTER AND OBLIGE ME.
POLICY NO.13400/34/08/87/00000019
RENEWAL REF.13400/34/07/87/00000007