Medical Insurance Rejection of Claims

Medical Insurance claims processing

   
  • Best option for the consumer is to obtain Cashless facility i.e. the Insurance company pays the bills directly to the hospital. But the hospital must be part of their preferred network (PPN), which list should be available on the insurance company website.

  • If you wish to take treatment in a hospital, which is not on the PPN cashless list, then make sure you intimate the Insurance company/ TPA within 24 hours of admission in any hospital.

  • In case of a pre-planned surgery, it is better to inform the Insurance company/ TPA much earlier.

Medical Insurance Rejection of Claims

Disputes resolution, especially Claims processing

As per IRDA guidelines, grievances must be acknowledged by the Insurance company in 3 working days and it must be resolved in 15 working days. For claims-related complaints, consumers can write to the Grievance cell of the Insurance company and if there is no response, then write to complaints@irda.gov.in or call toll-free at 155255 or on www.igms.irda.gov.in or through post at:
Consumer Affairs Department
Insurance Regulatory and Development Authority (IRDA)
3rd floor, Parishram Bhavan,
Basheer Bagh, Hyderabad

Medical Insurance Rejection of Claims

For Grievances, this IRDA Call Centre offers a true alternative channel for policyholders, serving from 8 AM to 8 PM, Monday to Saturday in Hindi, English and various Indian languages.

For disputes of less than Rs 20 lakhs pertaining to claims settlement or any disputes regarding premiums paid/ payable and non-issue of insurance documents, the Insurance Ombudsman can be approached in writing within 1 year of dispute, at:

Office of Insurance Ombudsman
Jeevan Sewa Annexe, 3 floor
SV Rd, Santacruz (W), Mumbai 400054

Tel: 26106928/ 26106980/ 26106245
Email: ombudsmanmumbai@gmail.com or ombudsman@vsnl.net

The complaint can be made in writing by the customer himself (no lawyer is required). The Governing body of the Insurance Council also is located here. Submit your claim papers and once registered with the Ombudsman office, attach the following document:

http://www.diehardindian.com/ngo/download/ins-ombudsman.pdf

Health Insurance Regulations 2013There were no regulations at all in the medical industry since its inception, even for basic issues like claims settlement, policy renewal, senior citizens, etc and Rs 13,000 crore worth claims were passed annually, without any proper rules or regulations.
Based on a Public Interest Litigation (PIL 12 of 2011) filed by Gaurang Damani (author of this website), IRDA came out with regulations for the entire medical insurance (mediclaim) industry in February 2013. These regulations should benefit the over 7 crore citizens, who own a medical insurance policy in India.
   

Main features of the Health Insurance Regulations 2013:

  • Earlier claim cheques were issued to the customer by the TPA (Third party Administrator), but now the insurance company would have to write a claim cheque or ECS directly to the customer. This would eliminate the float that some of the TPAs were enjoying. Also, there was never any public audit of the claims funds sanctioned by the Insurance company v/s actual amount disbursed by the TPA.
  • Claim would be settled by Insurance company only. TPA’s can only process claim. Claim documents would be electronically transferred to the Insurance Company for settlement.
  • Incentives can no longer be given to TPA’s to reduce claims.
  • Any claim which is denied, must be accompanied by a valid medical reason.
  • Claim settlement should be within 30 days and any delay beyond that would attract an interest payment to the customer of 2% over the prevailing bank rates.
  • Uncomplicated ONE page customer info sheet must be part of the Policy document and it would also mention the cumulative bonus (no-claim bonus amount)
  • Favourable claim ratio must be rewarded.
  • Separate grievance cell for senior citizens and their policy renewal cannot be denied randomly.
  • ID card to have logo of Insurance company (not of TPA) and there should be auto-renewal of this card. This would eliminate the need for the customer to keep track of their existing TPA.
  • Non-allopathic (AYUSH) treatments may be covered
  • Waiting period for pre-existing ailments must be clearly specified in the policy document

Other general guidelines:

  • Buy Insurance as early as possible, as lower your age, lower is the premium.
  • Generally Family floater policy is cheaper than buying individual policies for family members.
  • Generally exclusions and pre-existing diseases are not covered by a medical insurance policy (as specified in their policy document). Generally these could be covered after 2 years of holding the policy. Consumer must be honest in disclosing pre-existing ailments, if any.
  • Policy can be renewed within 15 days grace period after expiry of the policy. However coverage is not available for the days for which the premium was not received by the Insurance company.
  • One can transfer the policy from one Insurance company to another and the credits (including cumulative bonus) would also be portable.
  • New policy should be issued within 15 days of submission of proposal
  • Under the provision of Free-Look-Period, the consumer is given 15 days from the receipt of the policy document to go through the entire policy contract, and if you find any discrepancy in the policy contract you can return your policy to the insurance company and they will refund your premium amount without any deductions.
  • To keep a check that people dont try to take a policy where they have been diagnosed with some illness and they require immediate hospitalization, a 30 day waiting period is kept, where Insurance Company will not pay any kind of claim within the first 30 days of taking the new policy, (exception is that if policyholder meets an accident then the claim is payable).
  • Generally bed charges are 1-2% of the sum assured, depending on your Insurance carrier. All other charges like doctor visit etc. are often related to this bed charge, so it is important to be within these limits.
  • Co-Pay means that a certain percentage or a certain fixed amount of the claim has to be borne by the policyholder. If co-pay is 15%, then whatever is the hospital bill you will have to pay the 15% and balance 85% only will be paid by the Insurance company.
  • Under Section 80D, annual deductions upto Rs 15,000 can be availed of (Rs 20,000 for senior citizens)

For making life insurance policy claims:

  • Immediate intimation to the respective insurance company.
  • Submit the death certificate with complete medical history
  • Co-operate with claim investigator to complete his investigations, because all the insurance companies have outsourced their claim works to a private company and unless their report is cleared, the claim can not be settled.

About the author

2 Comments

  • saurav says:

    where can we find the complete judgement of the PIL filed in 2012 by Mr Damani author against Health insurance company

    View Comment
  • satya says:

    I am going for a planned surgery. And my company is in process of taking group health policy. Can the insurance company deny my claim because of my pre planned surgery.

    View Comment

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