Son discharged, medical bills of 35 lakhs! Insurance issues confusing cashless claim, where do I go?

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.   

Ans: Hi Anand, very sorry to hear about your plight. Seeing that you are not getting any response from the insurer, my advice would be that you approach ombudsmen and register your complaint. You need to email them at complaints@irdai.gov.in with your query along with all the documents of your case.

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: I'm truly sorry to hear about your husband's health complications and the subsequent challenges with your medical insurance. Facing such situations can be distressing, especially when dealing with unexpected denials and cancellations. It's important to take action to address this issue.

Firstly, gather all relevant documents, including policy details, correspondence with the insurance company, and any communication with the agent. This documentation will be crucial in understanding the reasons for the denial and in any potential appeals or legal actions.

Next, consider reaching out directly to the insurance company to request a review of the decision and clarification on why the claim was rejected. If you're unsatisfied with their response, you may escalate the matter through their grievance redressal mechanism or regulatory authorities.

Additionally, seeking legal advice from a lawyer who specializes in insurance matters could provide insight into your rights and options for recourse. They can help you navigate the complex legal landscape and pursue appropriate action to recover your hard-earned money.

While the situation is undoubtedly challenging, remember that you're not alone. Reach out to consumer rights organizations or advocacy groups that may offer support and guidance in dealing with insurance-related issues. Your perseverance and determination to seek justice are commendable, and I hope you find a resolution that provides the relief and security you deserve.