Good evening! I have gone through your answers on reading getahead. I have question for “AYUSH” for which I’m paying premium and the insurance company is not advising how to make claims for my Homeopathic treatments where I’m being charged special premium for “AYUSH”.

The insurance company is asking me minimum 24 hours of admission to claim. Unfortunately, there’s no facility for Homeopathy Treatment Hospitalisation. I request you to please share your knowledge on the same.

Ans: Hi Bhupesh, there is no ‘one size fits all’ concept with health insurance. Health insurance is based on preferences of the customer and then the premium quotes are generated based on those factors. You can use insurance broking websites to compare the offerings on the mentioned 5 factors and the premiums for various policies that will help you to compare their benefits and make an informed choice. Depending on your priorities, weigh out the factors and decide accordingly.

Since you have mentioned about your family, you can opt for Family Health Insurance policies with an appropriate sum insured to cover your entire family. Like I have mentioned before, premiums are unique to individuals depending on their preferences, the sum insured they deem suitable, the riders they choose, their medical history etc.

What you can do to ensure you buy the correct policy for yourself is to evaluate policies carefully, keeping in mind the 5 important parameters.

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Ans: Health check ups are not covered in medical insurance however check your policy if it offers free health check up

Ans: The coverage for OPD (Out-Patient Department) Ayurvedic/Homeopathic treatment under New India Assurance's Good Health Plan depends on the specific plan variant you have chosen. Here's how to find out:

Review your policy documents: The brochure or policy wording you received with your Good Health Plan will detail the inclusions and exclusions of the plan. Look for sections related to OPD benefits or Ayurvedic/Homeopathic treatment coverage.

Contact New India Assurance: Their customer service representatives can clarify your specific plan details. You can find their contact information on the company's website (https://www.newindia.co.in/) or on your policy documents.

Here's some general information based on publicly available details (it's crucial to confirm with your policy documents):

New India Premier Mediclaim Policy: This popular plan offers OPD coverage for Plan B after every block of two continuous claim-free years. This OPD benefit covers consultations, medicines, investigations, and dental treatment, but it likely excludes Ayurvedic/Homeopathic treatments.
Other Plans: New India Assurance offers various health insurance plans. Some might offer OPD coverage with Ayurvedic/Homeopathic treatment inclusion, but it depends on the specific plan variant.
Here's a recommendation:

Check your policy documents for the most accurate information.
If you're unsure, contact New India Assurance customer service for clarification.

Ans: Certainly! The process for filing a claim for cashless mediclaim with United India Assurance may vary slightly based on the specific policy and the nature of the medical event, but here is a general step-by-step guide that you can follow:

1. Inform the Insurance Company:

In case of planned hospitalisation, inform United India Assurance in advance. For emergencies, inform them as soon as possible.

2. Verify Network Hospitals:

Ensure that you are admitted to a hospital that is within the network of hospitals affiliated with United India Assurance for cashless claims.

3. Pre-Authorisation Process:

For planned hospitalisation, you need to obtain pre-authorisation from the insurance company. This involves submitting relevant documents such as the doctor's recommendation, estimated medical expenses, and other required information.

In an emergency, if pre-authorisation cannot be obtained in advance, inform the insurance company at the earliest opportunity.

4. Collect Necessary Documents:

Gather all relevant documents, including the policy document, ID proof, claim form, medical records, hospital bills, diagnostic reports, and any other documents required by the insurance company.

5. Submit Claim Form:

Fill out the claim form accurately. You can obtain this form from the hospital, the insurance company's website, or their customer service.

6. Submit Documents to the Hospital:

Provide the necessary documents to the hospital's insurance desk. The hospital will then submit the claim form and documents to the insurance company for processing.

7. Approval/Rejection of Claim:

The insurance company will review the submitted documents and decide whether to approve or reject the claim. If approved, the insurer will directly settle the bills with the hospital.

8. Paying Non-Covered Expenses:

If there are any expenses not covered by the insurance policy or if the claim is rejected, you may need to settle those directly with the hospital.

Reimbursement Claims:

• If you paid the medical expenses out of pocket, you can file for reimbursement
• Obtain all original bills, receipts, and medical reports
• Fill out the reimbursement claim form
• Submit the form along with the supporting documents directly to the insurance company within the stipulated time frame.

Follow-Up:

• Keep track of your claim's status by following up with the insurance company if necessary.
• Retain copies of all documents submitted for your records.

Always refer to the specific terms and conditions of your insurance policy and contact United India Assurance's customer service for any policy-specific details or clarifications. The contact information for United India Assurance can typically be found on their official website or in your policy documents.

Ans: There are a few reasons why third party administrators (TPAs) might hesitate to reimburse genuine health expenditure incurred on Ayurvedic treatment, even if all conditions are fulfilled and proofs are submitted.

• Ayurveda is not mainstream medicine: While Ayurveda is an ancient and recognised form of medicine in India, it is not considered mainstream medicine by some insurance companies. This means that TPA might not have clear guidelines for processing and approving Ayurvedic treatment claims.
• Lack of standardisation: There can be a lack of standardisation in Ayurvedic practices and treatments. This can make it difficult for TPAs to assess the validity and legitimacy of a claim.
• Cost-containment: TPAs work for insurance companies, and insurance companies are in the business of making money. This means they may be looking for reasons to deny or delay claims. Ayurvedic treatments can sometimes be expensive, and TPAs may be looking for ways to control costs.

Here are some things you can do if your TPA is not processing your claims for Ayurvedic treatment:

• Review your policy documents: Carefully read your insurance policy documents to understand the coverage for Ayurvedic treatment. Look for exclusions or limitations that might apply.
• Contact your TPA: Call your TPA's customer care department and ask them to explain why your claim was denied. Be polite but persistent in getting answers.
• File an appeal: If you are not satisfied with the TPA's explanation, you can file an appeal. The appeal process will vary depending on your TPA, but there should be information on how to file an appeal in your policy documents or on the TPA's website.
• Contact your insurance company: If the appeal process is unsuccessful, you can contact your insurance company directly. Explain the situation and ask them to intervene on your behalf.
• Consider legal action: If all else fails, you may want to consider taking legal action against your TPA or insurance company. This should be a last resort, as legal action can be expensive and time-consuming.

Here are some resources that you may find helpful:

• The Insurance Regulatory and Development Authority of India (IRDAI) is the regulatory body for the insurance sector in India. The IRDAI website has information on filing complaints against insurance companies and TPAs https://irdai.gov.in/.
• The Consumer Affairs Department of the Government of India also has a website where you can file complaints against companies https://consumerhelpline.gov.in/.