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Insurance Expert - Answered on Jun 21, 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

Question by S on Jun 21, 2022Hindi

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.

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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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.

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Question by Gora - Nov 24, 2022Hindi

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.