Hi Mayank.
I am 38 years old and have 18 years experience in account and finance. Recently my company put me on PIP (performance improvement plan) saying when we give any important work you go on sick leave. It happend twice when I was given some work and got sick. In 2021 due to cataract I could not download some work. Recently again they gave me some and I got hospitalised due to typhoid. These are uncontrollable events you cannot fell sick as per your will but they are not understanding.
Should I accept PIP although I have not made any big mistake in my work.
Kindly reply me.

Ans:

Hi Anand.

First of all, your employer is legally liable to provide paid leave. You must raise this issue with your management along with other colleagues.

You can even take the matter to the labour authorities.

At the same time, leaving your job without a proper back-up plan is not at all advisable.

If you want to start your own business, make a proper plan first and see if you can test it before you leave your job.

Ans: Hi Mittal, as far as I have understood your query, your sum insured exhausted during the hospitalisation process. Once the sum insured is exhausted, you cannot claim post hospitalisation bills.  

However, if your sum insured was not completely exhausted, you would have got the claim for post hospitalisation even if the bills were dated in Jan 2022, i.e. within 60 days of discharge.

Ans: I'm sorry to hear about your father's health issues and the challenges you're facing with the insurance claim. The denial of the claim by the TPA (Third Party Administrator) could be due to several reasons, including discrepancies in documentation, interpretation of policy terms, or classification of the treatment as investigational rather than therapeutic.

To address this issue and explore the possibility of reimbursement, here are some steps you can take:

Review Policy Documents: Carefully review the terms and conditions of your father's health insurance policy to understand the coverage and exclusions. Pay attention to the criteria for claim eligibility and the definition of covered treatments.

Seek Clarification: Contact the TPA or the insurance provider to seek clarification on why the claim was denied. Request detailed information on the specific reasons for denial and ask for clarification on any policy terms that are unclear.

Gather Documentation: Gather all relevant medical records, including discharge summaries, prescription details, invoices, and receipts for medications and treatments provided during the hospital stay. Ensure that the documentation clearly demonstrates the medical necessity and therapeutic nature of the treatment received.

Appeal the Decision: If you believe that the denial was incorrect or unjustified, consider filing an appeal with the insurance company. Provide supporting documentation and any additional information that may strengthen your case for claim reimbursement. Follow the appeal process outlined by the insurance provider and submit the appeal within the specified timeframe.

Consult an Expert: If necessary, consider seeking assistance from a healthcare advocate or insurance specialist who can help navigate the appeals process and advocate on your behalf. They may offer valuable insights and assistance in presenting your case effectively.

Explore Legal Options: If all attempts to resolve the issue through the appeals process are unsuccessful, you may consider seeking legal advice to explore further options, such as mediation or legal action, to resolve the dispute.

It's important to remain persistent and proactive in pursuing reimbursement for legitimate medical expenses. Keep thorough records of all communications and documentation related to the claim, and continue to advocate for your father's rights as a policyholder.

Ans: Dear G

I can appreciate your situation, while you may have all the proof, however I would suggest avoid legal battle. Imagine even if you win the case will company people support you when you work with them.

Better part ways in good terms and seek alternative job.

All.the best.