Health insurance

Dear sir,

    Please read the conditions mentioned in the policy bond. Then only we can get the conclusion

Best regards

Believe me, all the terms and conditions of PSU companies are similar, the charges to be reimbursed are uniform and well laid down in the form of the understanding document.  There was negligence somewhere, as the hospital should first take prior permission for the amount to be reimbursed by the insurance company and they have to restrict within that amount.   However, because the expenses are being borne by insurance, some patients try to spend as more amount as possible.  For example, if the insurance company stipulates a room to be shared by two without AC, the patient prefers an AC room with a single occupation.  Depending on the patients, the hospital authorities exploit them.  Each operation, treatment was defined with a fixed price for operation showing various details of expenses.

There is no guarantee that one insurance company is better than others, as everyone has to act as per laid down charts/conditions/treatment.  If your insurance company is a Public Sector Company, file RTI Application, and seek information from them and the reasons for disallowing Rs.72,000/- actual expenses.  You can also file RTI Application to another insurance company of your choice and can seek information on the reimbursement eligibility of insured for Hystreoctomy operation under the health insurance policy.  (There is some misunderstanding about the insured amount.  Because the policy is for Rs.5 lakhs, one can not expect that irrespective of actual treatment charges, anyone can get reimbursement up to Rs.5 lakhs irrespective of disease. The operating expenses of each disease are fixed and uniform, if for a disease like cancer, organ transplantation, open heart surgery the cost of operation is Rs.10 lakhs fixed, the maximum amount that can be claimed is only Rs.5 lakhs. Likewise if a minor operation costs Rs.30,000/- (Broken bones during an accident), one can not stay in AC room for 21 days and spend Rs.2 lakhs when the prescribed treatment is only for 5 days in ordinary sharing ward)

Originally posted by : Vishal Sharma
	Respected experts, My eldest sister (senior citizen) underwent hysterectomy ( uterus removal) operation in a hospital last week. She had a health insurance policy (New India Assurance) for Rs 5 lacs ( in continuation for last 6 years without any claims). She was sanctioned Rs 60000 only towards cashless hospitalisation. Before discharge the hospital requested for an additional cashless sanction as the total bill came to around Rs 132000. But the request was rejected . My sister was compelled vo pay the balance amount inspite of getting insured to the tune of Rs 5 lacs. Now my sister is seriously thinking of porting her policy to some other Insurance company. Kindly advice in this regard or as to which insurance is best. Regards.

1. You can consider filing a revised application with the Insurance Co., for relief, in terms of raising /passing enhanced claim amount.  Try to involve the Insurance Agent for settlement.

2. You have an positive option to file a grievance petition against both (the Insurance Co., AND the Hospital), in the local Consumer Court, for their illegal trade practice, negligence, deficiency, harassment, intimidation, etc.... with proper documentary evidences and you can claim damages /compensation & interest, and for your physical & mental trauma.

Keep Smiling .... Hemant Agarwal
VISIT: www.chshelpforum.com

Has your sister pursued the grievance before the designated authorities/forum? Running away from issues soles no problem. It is likely that porting the policy, she may be only be landing in the frying pan from the hot water.