My father is 89 years old and has recurring abdominal pain from last few months. In Apr'23 he was admitted in one private hospital at our locality and admitted for 7 days due to the pain issue. Various tests were conducted including blood tests, CT scan, fibroscopy and endoscopy, no major issues observed except some liver irregularities and discharged after providing certain oral medication. The cashless benefits are obtained through corporate TPA (EWA). However after certain weeks intermittently severe pain recur for almost a week and this time, on first week of July, my father was taken to Kolkata at a hospital specific to liver and digestive treatment. As advised by doctor he was admitted and again various tests are conducted including blood and stool culture, LFT, CT scan and colonoscopy..But this time also no major issues observed and he was discharged after certain medications, which differs from earlier hospital medicines. But this time claim is denied by TPA (EWA) stating that the admission is done only for investigation and observations and no line of treatment was done.. although new medicines are prescribed in the discharge summary and along with that IV fluid and some other medicines were regularly given during his stay in hospital. As TPA has denied the claim, I have to pay the entire amount in spite of paying a hefty amount of premium for my father. Can you pls suggest, why the claim is denied and whether there is any possibility of reimbursement of the claim by any means?

Ans: Hi Gaurang, TPAs have a cashless tie-up with the insurer and if the claim is as per the policy coverage, then the claim will be entertained by the insurer. If this is not happening, given that all submitted documents and requirements are as per the policy, then you can raise this issue with the insurer’s grievance authority or their organisational ombudsman.

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 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: 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: 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/.