Need details for redressal on rejected mediclaim

You have not given the reason. It shall be appropriate to mention the reason quoted by TPA for rejecting your claim.

1.Please check the link:

https://www.thehindu.com/news/cities/Bangalore/article329800.ece

“The Insurance Ombudsman, who presently hears cases in Hyderabad and Bangalore”

For addresses Pls check the link:

https://www.irdaindia.org/ombudsmenlist.htm

 and go thru:

https://www.team-bhp.com/forum/indian-car-loans-insurance/78420-frequently-asked-questions-faqs-insurance-ombudsman-its-working.html

2. https://www.gbic.co.in/faq.html

                                     “7) How is the complaint to be lodged?

“The Complaint is to be made in writing and may be  lodged through personal approach or through post / fax / email(followed by hard copy).”

3. Lawyer is not required. However it shall be beneficial to avail the consultation of an experienced consumer cases lawyer, who can structure and draft your complaint in effective order.

4. No.

Even in a settled claim, if the member requires original prescripttions, lab reports, discharge summary, diagnostic reports, X-ray films, Ultrasound report, ECG etc, for continuing the treatment these are returned. Customer has to make a request. In case of group mediclaim policies thru employer usually a Mediclaim Helpdesk is created and company staff stationed in HO reports to concerned HR personnel and helps all the employees. You may take the help of HR personnel and take mediclaim helpdesk in loop.

Hi Kumar,

i'm moved by the detailed information you have provided. Thanks a ton for that.

The reason for rejecting the claim is below:

Clause Descripttion: Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence of presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home or at home under domiciliary hospitalisation as defined.

My ontention: It was a biopsy involving surgical procedure. There are Operation Theater charges, Surgeon charges & Anaesthetiatist charges. This cannot be comparable to the diagnostic study like x-ray or Laboratory examination which could be done in any laboratory without getting admitted to the hospital.

This exclusion clause is intended to protect the insurer in cases wherein hospitalization is resorted only with the intention to bring the expenses within the ambit of the insurance.  Hence applying this clause in a case where there was a genuine need for hospitalisation is not in true spirit of the clause.

Also, refusing claim in genuine hospitalization case defeats the basic purpose of availing the mediclaim policy.

You may :

-involve HR which has obtained this policy and point out the unfair stand taken by company and thus involve the concerned office and official of the insurance company which has negotiated the policy and benefits for company/employees.

-involve the hospital and charge them for abusing the good faith, unfair practice resulting in rejection of your claim, as pointed out by insurance company TPA, and demand that an explanation be given to TPA to the level of satisfaction that your claim is justified and your hard earned monies are refunded.

You may inform the TPA in writing with a copy to local BM of the insurance company, your HR personnel, mediclaim helpdesk and mention that you have passed on the contentions of TPA to hospital and till the satisfactory reply of the hospital is received, no delay can be claimed by TPA or insurance company.

It shall be appropriate if you obtain the expert services and advice of an expert lawyer handling consumer cases/especially insurance claims. Off the record you can also consult insurance company’s experienced official.

Hi Kumar,

I will really appreciate your advice here.

Last year I was diagnosed with Hypertension. During my pregnancy, Sep 2012, I was hospitalised due to hypertension. Unfortunately we also lost our new born after 4 days. Since then we have seen number of doctors and conducted several tests to understand the cause. Since I have been on medication to control my high BP.

On march 16th due to certain symptoms I learnt that my BP had shot up to 200/140. Doctor was called home who gave me oral medications, but that failed to control it. He advised immediate hospitalisation. At Thunga hospital, doctor advised us to get admitted to an ICU. I was in ICU for 24 hours and during this period I was given some injections to lower my BP; and then was moved to another ward for another 24hours for further observation.

Oral medication billed to some Rs.600 and the remaining was some Rs.14870 was for tests, ICU and other room charges and several doctor visits. My Husband's Group mediclaim through TPA-GHPL  rejected our claim stating the medical bill was only Rs.600 and hence this was only investigative hospitalisation and not active line of treatment. Please advise the next steps and if we should involve a lawyer to fight this case.

Best Regards,

Heena