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Sanjib Jha |66 Answers |Ask -Follow

Insurance Expert - Answered on Nov 24, 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 K on 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.

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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Sanjib Jha |66 Answers |Ask -Follow

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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Sanjib Jha |66 Answers |Ask -Follow

Insurance Expert - Answered on Jun 21, 2022