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Ramalingam Kalirajan |7413 Answers |Ask -Follow

Mutual Funds, Financial Planning Expert - Answered on May 08, 2024

Ramalingam Kalirajan has over 23 years of experience in mutual funds and financial planning.
He has an MBA in finance from the University of Madras and is a certified financial planner.
He is the director and chief financial planner at Holistic Investment, a Chennai-based firm that offers financial planning and wealth management advice.... more

Question by Nishat on Mar 26, 2024Hindi

Hi sir, my mother taken health insurance from religare in 2019 for 3 year..she switched to Bajaj in 2022 for next 3 year..when she claimed for cataract surgery Bajaj rejected due to 2 year waiting period. Previous policy waiting period not carry forward. What should she do?

Ans: I understand your concern about your mother's health insurance claim being rejected due to the waiting period clause. Here's what she can consider doing:
1. Review Policy Documents: First, carefully review the policy documents of both the Religare and Bajaj health insurance plans to understand the terms and conditions regarding waiting periods, coverage, and claim procedures.
2. Contact Bajaj Customer Support: Reach out to Bajaj's customer support or claims department to discuss the situation and seek clarification on the rejection of the claim. Provide all relevant details and documentation related to the policy switch and the cataract surgery.
3. Appeal the Decision: If Bajaj maintains its decision to reject the claim, consider filing an appeal with the insurance company. Provide additional information or documentation if available to support the claim and demonstrate the necessity of the surgery.
4. Seek Assistance from Insurance Ombudsman: If the appeal with Bajaj does not yield a satisfactory outcome, your mother can approach the Insurance Ombudsman for assistance. The Insurance Ombudsman is a regulatory authority that resolves grievances and disputes between policyholders and insurance companies.
5. Consult Legal Counsel: In cases where the insurance company's decision appears to be unjust or in violation of the policy terms, seeking legal advice from a qualified lawyer specializing in insurance law may be necessary. They can provide guidance on the available legal options and represent your mother's interests if required.
6. Consider Policy Renewal Options: Depending on the circumstances, your mother may also explore options for switching to a different health insurance provider or policy during the next renewal period. Ensure thorough research and comparison of policy features, coverage, waiting periods, and claim settlement records before making a decision.
It's essential to act promptly and diligently in addressing the issue to ensure that your mother receives the rightful coverage and benefits under the health insurance policy.

Best Regards,
K. Ramalingam, MBA, CFP,
Chief Financial Planner
www.holisticinvestment.in

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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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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Question by Gora - Nov 24, 2022Hindi

I was customer of Oriental Bank of Commerce. Being a customer of Oriental Bank of Commerce, Oriental Insurance Company provided Group Health Insurance Policy and inception date was 04-05-2015. My policy with them continued till 03-05-2021 without any break. Because Oriental Bank of Commerce merged with Punjab National Bank, Oriental Insurance Company discontinued that policy from 03-05-2021 onward. Being a customer of Punjab National Bank, I approached them, and they migrated my Group Health Insurance Policy of Oriental Insurance Company to Star Group Health Insurance Policy for customers of Punjab National Bank from 04-05-2021 to 03-05-2022. As All my policy periods were continued from 04-05-2015 till 03-05-2021 with Oriental Insurance Company, Star Health Insurance given me the benefit of pre-existing disease waiting periods being waived because of continuity (They mentioned it in Policy Document too). They reimbursed my 1st claim of 15 July to 22 July 2021 (Non Empaneled Hospital) and Cashless claim of 16 December to 19/12/2021 but denied reimbursement of 19/12/2021 to 26/12/2021 with the excuse of pre-existing disease even I directly shifted from cashless hospital to non-Empaneled Hospital for same problem because Empaneled hospital having been less facilities. Here I want to address that I was discharged from Cashless Hospital, on request, to get treated in Higher Hospital and treatment was in continuation of previous cashless hospital to new hospital. So, sir, please guide me accordingly as my correspondence with them is not fruitful.

Ans: Hi Gora Lal Gargi, to solve your query I will need more information. Firstly, please do check if your sum insured value was exhausted in the first claim.

If yes, then check the policy document to know if your insurer provides claim for same person, same illness on the second claim i.e. restoration benefits.