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Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on Nov 24, 2022

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
Gora Question by Gora on Nov 24, 2022Translate

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.

Ans: Hi Gora Lal Gargi, to solve your query I will need more information. Firstly, please do check if your sum insured value was exhausted in the first claim.

If yes, then check the policy document to know if your insurer provides claim for same person, same illness on the second claim i.e. restoration benefits.

In case, the sum insured is not exhausted then you are eligible for the second claim and I advise you to write to ombudsmen about your issue. You need to email them at complaints@irdai.gov.in (external link) with your query along with all the documents of your case. 

DISCLAIMER: The content of this post by the expert is the personal view of the rediffGURU. Users are advised to pursue the information provided by the rediffGURU only as a source of information to be as a point of reference and to rely on their own judgement when making a decision.

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Sanjib Jha  | Answer  |Ask -

Insurance Expert - 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.


Sanjib Jha  | Answer  |Ask -

Insurance Expert - 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.   


Moneywize   |66 Answers  |Ask -

Financial Planner - Answered on Jan 31, 2024

Asked by Anonymous - Jan 30, 2024Translate
Hi I have taken an insurance Policy : Click 2 Protect 3D policy. its a combi policy where Term Insurance is from HDFC Life and Health Insurance from ERGO (In first year it was Apollo Munich). Its been 5 years since I have been paying the premiums, every year the health premium increased. Recently I paid 60k as premium where initially it was 54k. here Term is around 18K odd, rest is for health. I feel I am being charged more for lesser benefits, the insurance covers my wife and two kids (9 years) and me. By God's Grace till date its no claim policy. The base cover is 4L and added benefits is 4L. I see , their counter parties offer more benefits for such an amount say 40K. i tried to shift to Star Health but portability denied saying it is not possible since it is combined policy. Here i want more cover or able to port to other service provider. What shall I do?
Ans: It's understandable that you're concerned about the increasing premiums and the perceived lack of benefits in your current insurance policy. Here are some steps you can consider:

• Review Your Policy Documents: Make sure to thoroughly review your insurance policy documents. Understand the terms and conditions, coverage details, and any clauses related to premium increases. It's essential to be aware of the specifics of your current policy before making any decisions.
• Compare Policies: Compare the benefits and premiums of your current policy with those offered by other insurance providers in the market. Look for policies that provide similar or better coverage at a more reasonable cost. Take into account the coverage for both term insurance and health insurance.
• Contact Your Current Provider: Reach out to HDFC Life and ERGO to discuss your concerns. Inquire about the reasons for the premium increase and whether there are any options to customise your policy to better suit your needs without compromising coverage. Sometimes, providers may have different plans or options that could better fit your requirements.
• Explore Portability Again: Since you mentioned that Star Health denied portability, consider reaching out to other insurance providers to explore portability options. Different providers may have different policies on porting combined policies, and it's worth checking with multiple companies.
• Seek Professional Advice: Consult with a financial advisor or insurance expert to get personalised advice based on your specific situation. They can help you understand the nuances of your policy, assess your needs, and guide you on the best course of action.
• Consider Separate Policies: If portability remains challenging, you may explore the option of having separate term insurance and health insurance policies from different providers. This way, you can tailor each policy to your specific needs and potentially save on costs.
• Stay Informed About Regulatory Changes: Keep yourself informed about any regulatory changes in the insurance industry that may impact your policy. Sometimes, regulatory changes can affect premium calculations or portability options.

Remember that making changes to insurance policies requires careful consideration, and it's crucial to ensure that you maintain adequate coverage for your family's needs. Always read the terms and conditions of any new policy thoroughly before making a decision. If needed, seek legal or financial advice to make an informed decision.
Latest Questions

Moneywize   |66 Answers  |Ask -

Financial Planner - Answered on Mar 03, 2024

Asked by Anonymous - Mar 03, 2024Translate
I'm contemplating a career change in my late 30s, earning Rs 14 lakhs annually. How can I navigate this transition while ensuring financial stability and working towards long-term goals such as retirement?
Ans: Transitioning to a new career in your late 30s while maintaining financial stability and planning for long-term goals like retirement requires careful consideration and planning. Here are some steps you can take to navigate this transition effectively:

1. Assess Your Skills and Interests: Reflect on your skills, interests, and values to identify potential new career paths that align with your strengths and passions. Consider seeking career counseling or taking career assessment tests to explore different options.

2. Research Potential Careers: Conduct thorough research on the industries and roles you're interested in pursuing. Look into job market demand, salary potential, and growth opportunities to ensure your chosen career path is financially viable.

3. Skill Development and Education: Determine if you need to acquire new skills or education to transition into your desired field. This could involve enrolling in courses, obtaining certifications, or pursuing higher education such as a degree or specialised training programme.

4. Financial Planning: Evaluate your current financial situation and create a budget to understand your income, expenses, and savings. Factor in any potential changes in income or expenses associated with your career transition. Consider setting aside an emergency fund to cover unexpected expenses.

5. Debt Management: If you have any outstanding debts, develop a plan to manage and pay them off efficiently. Prioritise high-interest debts like credit card debt while maintaining minimum payments on other loans.

6. Retirement Planning: Review your retirement savings accounts like the EPF, and assess whether you're on track to meet your long-term retirement goals. Consider consulting a financial advisor to develop a personalised retirement plan based on your age, income, risk tolerance, and retirement objectives.

7. Health Insurance and Benefits: Evaluate the health insurance and other benefits offered by your new employer, if applicable. Ensure you understand the coverage provided and any associated costs. If transitioning to self-employment or freelancing, research options for obtaining health insurance coverage independently.

8. Networking and Building Connections: Network with professionals in your desired industry to gain insights, advice, and potential job opportunities. Attend industry events, join professional associations, and leverage online networking platforms like LinkedIn to expand your network.

9. Side Hustle or Freelancing: Consider starting a side hustle or freelancing in your desired field while maintaining your current job. This can provide additional income, valuable experience, and a smoother transition into your new career.

10. Evaluate Risks and Rewards: Assess the risks and rewards associated with your career change, including potential income fluctuations, job stability, and work-life balance. Be prepared to adapt and make adjustments as needed throughout the transition process.

By following these steps and carefully planning your career transition, you can navigate the change while maintaining financial stability and working towards your long-term goals, including retirement.
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DISCLAIMER: The content of this post by the expert is the personal view of the rediffGURU. Investment in securities market are subject to market risks. Read all the related document carefully before investing. The securities quoted are for illustration only and are not recommendatory. Users are advised to pursue the information provided by the rediffGURU only as a source of information and as a point of reference and to rely on their own judgement when making a decision. RediffGURUS is an intermediary as per India's Information Technology Act.


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