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Sanjib Jha

Insurance Expert 

54 Answers | 3 Followers

Sanjib Jha is the CEO of Coverfox Insurance. His expertise includes health and auto insurance. He has over 22 years of experience in the financial sector. He has completed his post-graduation from the Institute of Company Secretaries of India.... more

Answered on Nov 24, 2022

I was customer of Oriental Bank of Commerce. Being a customer of Oriental Bank of Commerce, Oriental Insurance Company provided Group Health Insurance Policy and inception date was 04-05-2015. My policy with them continued till 03-05-2021 without any break. Because Oriental Bank of Commerce merged with Punjab National Bank, Oriental Insurance Company discontinued that policy from 03-05-2021 onward. Being a customer of Punjab National Bank, I approached them, and they migrated my Group Health Insurance Policy of Oriental Insurance Company to Star Group Health Insurance Policy for customers of Punjab National Bank from 04-05-2021 to 03-05-2022.  As All my policy periods were continued from 04-05-2015 till 03-05-2021 with Oriental Insurance Company, Star Health Insurance given me the benefit of pre-existing disease waiting periods being waived because of continuity (They mentioned it in Policy Document too). They reimbursed my 1st claim of 15 July to 22 July 2021 (Non Empaneled Hospital) and Cashless claim of 16 December to 19/12/2021 but denied reimbursement of 19/12/2021 to 26/12/2021 with the excuse of pre-existing disease even I directly shifted from cashless hospital to non-Empaneled Hospital for same problem because Empaneled hospital having been less facilities.  Here I want to address that I was discharged from Cashless Hospital, on request, to get treated in Higher Hospital and treatment was in continuation of previous cashless hospital to new hospital. So, sir, please guide me accordingly as my correspondence with them is not fruitful.

Answered on Oct 12, 2022

 I am an employee of central govt. PSU. My family consists of myself, spouse, two minor children and mother. I am covered by a corporate group medical insurance policy for Rs 2 lakh with an additional emergency coverage of Rs 4 lakh by the employer. I also have a personal Family Floater policy for Rs 3 lakh and a Sr. Ctzn. Policy for Rs 1 lakh. I have not used the personal policies till date for any hospitalisation claim. I am aware that a claim exceeding the corporate policy limit can be claimed in the personal policy. Recently I was made to know that any planned hospitalisation exceeding the corporate claim limit, cannot be done using the second policy. I also know that there is a product called as top up policy which can be used in such cases. I have 8 years of remaining service where there is a medical insurance cover during the period. After retirement, the employer provides a basic policy of 1.5 lakh for the family. The same feels to be insufficient in today’s times. What would be your advice with regards to the existing medical insurance policies and their amounts? Should I need to undertake any tweaking of the policy amounts or switch to a top up policy?
Ans: Hi Pradeep, yours is a legit concern. It would be best if you take advice from a professional person or company – having the necessary qualifications -- after discussing your issue with them.

Insurance is each to its own. Depending on your concerns and requirements a professional service provider will be able to give you the best advice, whether to tweak policy amount or switch to top up.


Answered on Sep 23, 2022

I am 73 (DOB 10-07-1949). I had an open heart surgery in Sept., 1999. I am taking blood thinner otherwise ok. My wife is 66 (DOB 13-09-1956). She has no problems. I have a 5L Family Floater health insurance from Oriental Insurance - Bank Saathi Policy at an annual premium of about Rs. 35,000 for self and wife. Since in these days this is not sufficient, I want another policy for 5L or Top Up for 5 / 10 L for self and wife. Please advise an honest suitable minimum cost affordable policy since I have limited capacity to pay because my life time savings in Punjab & Maharashtra co-op Bank Ltd., Mumbai, has been looted by bank Management, Senior Employees, HDIL Construction Co. (Wadwhans), RBI, Politicians and Govt. Another point. Earlier I had policies with National Insurance, New India Insurance and Oriental Insurance from my Bank tie-up but one after the other they broke the tie up with Banks and offered their direct policy raising annual premium from 11,000 to 43,000 (National Insurance) and others also on same lines because they follow dishonest business policy and just want to loot the common man. How anybody can afford such increase after 8 years with Govt. co. insurance Policy? IRDA is also on their side being dishonest. Not only private but Govt. cos. are also dishonest, corrupt and want to kill the common man.
Ans: Hi Mr RN Mitra, sorry to hear about your condition, wish you good health and recovery.

As far as the top up plan is considered, given your age and pre-existing diseases, your risk profile is high and most insurers may not be able to offer Super top up plans.

The best option is to apply for a new base plan with a higher sum insured, however the premium will be on the higher side.


Answered on Jul 29, 2022

Answered on Jul 28, 2022

My Oriental Mediclaim coverage is for Rs 5 lakh under Royal Mediclaim cashless scheme vide PNB. I have completed 36 months, a conditional requirement (a facility only for PNB customer). In this regard I have a few questions...
Ans: Hi Anoop, thanks for sharing your queries, will take them one by one.

1. What's the meaning of 5 lakh coverage? Will I get a full 4.95 lakh for both knees transplant (my hospital package is costing 4.95 lakh from entry to exit)?

Sanjib Jha:  A coverage of 5 Lakh means your policy covers you up to 5 lakh and you can claim it. However, the coverage amount for knee transplant depends on insurer to insurer as few of the policies having certain capping on the coverage amount for such treatments.

2. When the hospital sent the proposal to TPA, only 2.47 lakh were provisional sanction. What's the meaning of provisional? I was told that the final amount will be settled once final bill is produced by the hospital. Does it mean that 4.9-2.47=2.43 lakh or so, will be settled and remitted to the hospital by Oriental insurance? 

Provisional Sanction amount is the amount that the insurer approves based on the ailment i.e., knee transplant in your case. The rest of the amount approval is provided based on the final bill generated by the hospital.

3. When I sought clarification from TPA, I was verbally told that now the final amount cannot be decided. Only after the final bill it can be. Nothing said on email. No replies from Oriental insurance of my email query.

For policies issued by Oriental, the claims are handled by TPA (Third Party Administrator). I advise you to raise the concerns to TPA via email or via TPA desk to get the clarification. Also, the insurer can provide the final approval after the final bill is generated by the insurer, deducting the non-approved cost as per policy terms & condition.

4. Hospital insists that I deposit 50% (2.5 lakh) cash from pocket before admission.

As it seems that the insurer has provided pre-approval for 2.47 lakh, the rest amount you will have pay to the hospital & the same will get approved by the insurer once the final bill is generated by the hospital.

5. If I have to pay cash, then where is the cashless scheme?

I advise you to check the terms of your policy. Often certain treatments are not covered in particular policies, which is why it is extremely important to read your policy document thoroughly and ask all your queries to the agent/Insurer before purchase. For specific ailments, there are add-ons offered by insurers and accordingly one should opt for those add-ons.


Answered on Jul 05, 2022

2. Would my base premium remain constant, or it would change over a period?

Yes, your premiums would increase over time and it depends on age brackets, claim experience and other factors. So, even if you opt for a health insurance plan earlier in life, your premium would go up almost every year or every 5 years, depending on your age, health conditions and other factors.

So, the natural question everyone would have is, why opt for a health insurance plan early? In any case, younger people need to claim their health insurance lesser than older people, right? So, should the younger ones wait to grow old before opting for a good HI plan?

In my opinion, the answer is NO and there are multiple reasons for the same.

a. Is there a guarantee that the young will not fall ill?

With COVID-19 second wave, we have seen that the young needed more hospitalisation than the old.

b. With the rise of lifestyle ailments, diabetes, obesity, digestive concerns and hypertension has taken a leap in the youth of India. Fitness and a healthy lifestyle, which have taken a backseat, need to be focused along with a large comprehensive health plan to tackle the issue.

c. The earlier you opt for a health insurance plan, the lesser likely it would be that you would have any pre-existing ailments. So, your coverage quantum would be higher than if you have any of the pre-existing lifestyle ailments.

d. Since the young usually need lesser hospitalisation than the old, your mandatory and specific waiting periods would be over before you actually need them.

The moral of the story is that you need to opt for a high health insurance plan as early as possible. You can always top it up later.


Answered on Jun 21, 2022

Dear Sir, Greetings of the day. I have got a health insurance of family floater type from Tata AIG for a sum of four lakhs. Recently, I got hospitalised and full four lakhs was paid by Tata Aig. But my hospital bill was six lakhs and sixty two thousand. So there was a shortfall of two lakhs sixty-two thousands. I have an Aditya Birla health Policy of family floater type for 45 lakhs. But it will come in to effect after 5 lakhs expenditure. So I myself paid one lakh from my pocket. And for rest one lakh sixty two thousand only I applied for cashless to Aditya Birla .But they denied it. Finally I paid that amount myself and came home. Afterwards I kept continuous follow up with them. Reconsideration and reminder letter was sent by TPA and Treating doctor. But again it was rejected. Now Aditya Birla employee is saying apply for reimbursement. When Tata Aig is clearing full amount, how come Aditya Birla is denying it? And how can I bridge the gap one lakh between two policies? Tata Aig says you have taken full claim so we cannot make your limit from four to five lakhs this year. Pls advise suitably. Best Wishes
Ans: Hi Mr. Tripathi, greetings to you. To answer your first question as to why Aditya Birla won’t provide you with cashless claim as opposed to TATA AIG is because the policy you bought from Aditya Birla is a ‘Super top up plan’ which basically means it is an addition to your base policy which in your case is your TATA AIG policy.

Super top up policies do not offer cashless claims but only provide reimbursements.

The one lakh gap, unfortunately, cannot be filled at this point. However, while renewing your policy you can opt for increased sum insured with TATA AIG. The insurer will ask you a set of questions and schedule medicals to analyse your risk profile. Post that based on your reports, the insurer will take a decision on increasing the limit.   


Answered on Jun 21, 2022

My family (aged 54 years) is covered under ECHS (Ex-servicemen Contributory Health Service) for the last thirty years. I have family floater health hospitalisation policy in two different insurance companies. Three years back, she had some issues related to her blood disorders. During the blood transfusions, we have made claims in the insurance cover. It took few months to diagnose the issue. Finally it was diagnosed as 'a type of blood disorder'. I have availed the hospitalisation and treatment facilities from ECHS. Now she has recovered (and under medication) for the last two years. She is leading normal life. My query is: Can I declare and have Critical illness included coverage in the health insurance? (Earlier I was denied as permanent exclusion -IRDA). Can I continue the existing health coverage from the insurance from other than Critical illness? (I can get ECHS facility, but there are limitations). Since she is alright, will the insurance companies accept? We are ready for relevant medical tests as required. We seek your advice.
Ans: Hi Thangavelu, good to know that your wife is doing well. To answer your first query, yes you can declare your critical illness and avail the rider for it. Another option is to purchase a new plan for critical illness from an insurer of your choice. The insurer will ask a set of questions and based on that the coverage will be provided. However, most of the insurers will keep the PED in the Permanent exclusion list. As far as your query on continuation of policy is considered, you can continue with the existing health policies you have.

Any medical condition which arises after the waiting period of the policy will be covered in the health policies. Which is why check for the waiting periods associated with different ailments in your policy document.


Answered on Jun 21, 2022

I am 83 and hale and hearty. My only passion is TRAVEL -- National and International. I have a daily routine to go for morning/evening walks along with light exercises at home. At the age of 76, I had IMPLANTATION of PACEMAKER and thereafter CABG. Health Insurance: No insurance company offers me a comprehensive Health policy with ADDS ON. I am offered HEART POLICY without ADDS ON like day care treatment, but EXCLUDING PACEMAKER. For this, their Premium is Rs.74000.00. I have no problem whatsoever as far as my Heart and Pacemaker, then why the insurance company can't include day care treatment. It's quite shocking that in our country, Health insurance is HARD CORE BUSINESS and IRDA and Govt. of India is aware of the happenings in Healthcare Insurance but keep their eyes closed. What a Pity!
Ans: Hi Ashok, it is great to know that you are maintaining a healthy lifestyle and living your life to the fullest. The concern raised by you is legit but the solution to it is simple – Buy the right kind of health insurance policies at an early age. When one purchases health insurance at an early age, the premiums they pay will be lower because their pre-existing diseases will be lesser and will not be considered a high-risk profile.

As our age increases, the chances of health deterioration increase which makes the premiums higher and in some cases a lot of diseases and ailments come with a longer waiting period and PED exclusion lists. During the time of issuance, each insurer analysis the risk via proposal form, medical reports and take decisions accordingly.

Age is an important factor in risk determination by the insurers and considers old age applicants as very high-risk profiles and hence doesn’t provide health policy. Few of the heart policies as said will provide coverage but will exclude the PEDs (pre-existing diseases).

This is why the Govt. of India, IRDAI, Insurers and broking companies like Coverfox Insurance are trying to educate the masses to purchase health insurance policies at a younger age and are constantly trying to inform people of the benefits of Health Insurance and how to choose the correct plan for oneself.


Answered on Jun 21, 2022

I have mediclaim policy from Oriental Insurance Co since 1992 for 5 lakhs and other from New India Assurance for 7.5 Lakhs under SCUM scheme with my spouse. However both the policies have set a limit of Rs. 40,000 for Cataract surgery even though I have been diagnosed with 1) Cataract Phaco with Panoptix IOL, 2) Pupilloplasty, 3) CTR Implantation for which a renowned hospital billed me as below for separately for each eye. 1) Cataract Procedure Cost. Rs. 27000/- which is approved by Oriental in their contract with Hospital 2) IOL Cost Rs. 49000/- 3) Pulilloplasty Rs. 6950/- after discount 4) CTR Implantation Rs. 1600/ after discount Now in Claim No. 1 Oriental approved. Rs 36,000/- Only and balance Rs 48500 I had to pay Claim No. 2 Oriental approved Rs.73,300/- Only and balance Rs.11250/- I had to pay Surgery was done 1 week apart. In my case I was advised Cataract with multifocal IOL + Pupilloplasty + CTR Implantation So, I need your advice on: How can Insurer Oriental approve and give different claim amount for each eye and how can I claim for reimbursement of balance amount I had to pay. Appreciate your guidance and help.
Ans: Hi Jyoti, hope you are doing well. As you have mentioned that the claim amount for each eye has been different, to understand the reason behind this disparity, you will have to check the documentation submitted to the insurer for both the surgeries. Request you to contact your insurance advisor and discuss the same with the insurer to understand this gap further and help you resolve this issue. 


Answered on Jun 10, 2022

My family is covered under Ex-serviceman Contributory Health Services (ECHS). She is having health insurance coverage from three other insurance entities. Still continuing. So, there was no pre-existing conditions. Two and half years back, we have opted for claim re-imbursement only for blood transfusions during the pre-diagnosis period. Later, her medical condition was diagnosed and the same was falling under IRDA exclusions. She was treated once in-patient and afterwards as outpatient. All claims for admission and medicine re-imbursement were availed from ECHS. (Once I have opted for enhancement of insurance coverage from one insurer and the TPA has refused under these clauses). Now, after two and half years, she has recovered better (Even Doctor's perception). But she is continuing medicine with lessor dosage. Presently, her condition is fine. My questions are: 1. Can I avail insurance facilities from insurance companies for the same issue in future?  2. Can I avail insurance facilities from the insurance companies, for other issues than the specifically excluded? 3. Can I prefer ECHS for any eventualities for the specified issue to the extent admitted, and remaining expenditure from other insurance companies? Please guide.
Ans: Hi Thangavelu, good to know that your wife is doing better. Coming to your questions, yes you can avail the insurance facilities for the same ailment in future from your existing insurance companies. However, if you purchase a new insurance policy from another company, then whether you get the coverage or not will depend on the ailment and the insurer.

For other ailments, at the time of issuance an insurer analyses the risks, given the ailment of the insured. Accordingly, the insurer takes a decision whether the policy can be issued or not, there are few insurers in the market that will keep the pre-existing diseases excluded or will have a waiting period for it. However, if your ailments have developed after the policy issuance then you can avail insurance facilities for those ailments.

Answering your third question, yes you can prefer ECHS for this specific issues and the remaining expenditure can be claimed from other insurers.