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Insurance Expert - Answered on Sep 08, 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 Pannkaj on Sep 08, 2022Hindi

I have an individual health policy with Nivabupa. The current renewed policy document mentions:

1. Base Sum Insured Rs 5 lakh

2. Loyalty Additions Rs 2 lakh

3. Next Column Sum Insured (Base Sum Insured + Loyalty Additions + Refill amount ^) (in Rs) 12,00,000

My 2 claims totalling Rs 6.25 lakh for Angiography and Bypass Surgery were settled only for Rs 500,000.

Is this in line with norms?

Ans: Hi Pannkaj,to answer your question we need to understand the plan details and the type of deduction done by the insurance company during the claim.

I suggest you speak with your insurer on why only Rs 500,000 was settled against your bills.

Also as a rule, do read all the terms and conditions on your policy document and the claim settlement process followed by your insurer.

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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Insurance Expert - Answered on Jun 21, 2022

Question by S - 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.

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Insurance Expert - Answered on Jun 21, 2022

Question by Jyoti - Jun 21, 2022Hindi

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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Insurance Expert - Answered on Oct 12, 2022

Question by Pradeep - Oct 12, 2022Hindi

I am an employee of central govt. PSU. My family consists of myself, spouse, two minor children and mother. I am covered by a corporate group medical insurance policy for Rs 2 lakh with an additional emergency coverage of Rs 4 lakh by the employer. I also have a personal Family Floater policy for Rs 3 lakh and a Sr. Ctzn. Policy for Rs 1 lakh. I have not used the personal policies till date for any hospitalisation claim. I am aware that a claim exceeding the corporate policy limit can be claimed in the personal policy. Recently I was made to know that any planned hospitalisation exceeding the corporate claim limit, cannot be done using the second policy. I also know that there is a product called as top up policy which can be used in such cases. I have 8 years of remaining service where there is a medical insurance cover during the period. After retirement, the employer provides a basic policy of 1.5 lakh for the family. The same feels to be insufficient in today’s times. What would be your advice with regards to the existing medical insurance policies and their amounts? Should I need to undertake any tweaking of the policy amounts or switch to a top up policy?

Ans: Hi Pradeep, yours is a legit concern. It would be best if you take advice from a professional person or company – having the necessary qualifications -- after discussing your issue with them.

Insurance is each to its own. Depending on your concerns and requirements a professional service provider will be able to give you the best advice, whether to tweak policy amount or switch to top up.

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Insurance Expert - Answered on Nov 24, 2022

Question by K - Nov 24, 2022Hindi

I have a Mediclaim insurance policy (senior citizens) from National Insurance co Ltd. My wife was operated for Knee replacement surgery. Against the claim of Rs 3.48 lakh, the claim was passed for 51000/- only. I wrote to the Insurance co and wanted to know the reason but no answer. I seek your help and guidance.

Ans: Hi KD, hope your wife has recovered. To answer your query, I advise you to check your policy document again. There are many health insurance policies that have capping/limitations on the list of ailments. You can find the same in the policy documents or policy wording.

I suggest you approach your insurance company and inquire about the same and if you still fail to get a response from them then you can approach insurer ombudsman for this issue.

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