Home > Money > Question
Need Expert Advice?Our Gurus Can Help
Sanjib

Sanjib Jha  | Answer  |Ask -

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
Mittal Question by Mittal on Nov 24, 2022Hindi
Listen
Money

I have been operated for Wilson's disease for my liver. I got admitted in Nov 21 and got discharged in Dec 21. My insurance company paid all expenses up to Sum insured and the same got exhausted in Dec 21 and then I renewed the policy in Jan 22. As per my Policy I am eligible for claiming 60-days medical expenses post hospitalisation and submitting the bills but the TPA is repudiated it with remarks that not eligible as the treatment done in 2021 and bills for 2022 are not admissible though the insurance company is same.

Please help to know how do I tackle it and is there any alternate possibility.

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.

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.
Money

You may like to see similar questions and answers below

Sanjib

Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on Jun 21, 2022

Listen
Money
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.   

..Read more

Sanjib

Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on Sep 08, 2022

Ramalingam

Ramalingam Kalirajan  |7097 Answers  |Ask -

Mutual Funds, Financial Planning Expert - Answered on Apr 05, 2024

Listen
Money
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: I'm sorry to hear about your father's health issues and the challenges you're facing with the insurance claim. The denial of the claim by the TPA (Third Party Administrator) could be due to several reasons, including discrepancies in documentation, interpretation of policy terms, or classification of the treatment as investigational rather than therapeutic.

To address this issue and explore the possibility of reimbursement, here are some steps you can take:

Review Policy Documents: Carefully review the terms and conditions of your father's health insurance policy to understand the coverage and exclusions. Pay attention to the criteria for claim eligibility and the definition of covered treatments.

Seek Clarification: Contact the TPA or the insurance provider to seek clarification on why the claim was denied. Request detailed information on the specific reasons for denial and ask for clarification on any policy terms that are unclear.

Gather Documentation: Gather all relevant medical records, including discharge summaries, prescription details, invoices, and receipts for medications and treatments provided during the hospital stay. Ensure that the documentation clearly demonstrates the medical necessity and therapeutic nature of the treatment received.

Appeal the Decision: If you believe that the denial was incorrect or unjustified, consider filing an appeal with the insurance company. Provide supporting documentation and any additional information that may strengthen your case for claim reimbursement. Follow the appeal process outlined by the insurance provider and submit the appeal within the specified timeframe.

Consult an Expert: If necessary, consider seeking assistance from a healthcare advocate or insurance specialist who can help navigate the appeals process and advocate on your behalf. They may offer valuable insights and assistance in presenting your case effectively.

Explore Legal Options: If all attempts to resolve the issue through the appeals process are unsuccessful, you may consider seeking legal advice to explore further options, such as mediation or legal action, to resolve the dispute.

It's important to remain persistent and proactive in pursuing reimbursement for legitimate medical expenses. Keep thorough records of all communications and documentation related to the claim, and continue to advocate for your father's rights as a policyholder.

..Read more

Latest Questions
Radheshyam

Radheshyam Zanwar  |1054 Answers  |Ask -

MHT-CET, IIT-JEE, NEET-UG Expert - Answered on Nov 21, 2024

Asked by Anonymous - Nov 21, 2024Hindi
Listen
Career
Hello, I am 3 yr neet dropper.in 2025 it will be my third attempt... I'm trying my best to crack neet ...i don't know what will happen will i score good marks or not ... please help me in suggesting good career options if not crack neet .....there are many options through neet marks also like bhms , veterinary...etc. i will also give entrance exam also like cuet ,gbpuat ,....but i want that what to choose which course will be best for me ...i want to make my life good and happy... having a good degree, good job ,...
Ans: Hello.
Have you analyzed your failure in 2 successive attempts in the NEET examination? If yes, then the question is what you have done for improvement and not then again the question arises why not? Here, I would like to suggest you focus now only on the NEET examination which is your 3rd attempt. Don't think about any other options right now till May 2025. After the NEET exam is over, you have ample time to explore the options available. Depending on your score in NEET 2025, we will guide you at that time. But yet, if you are confused, then looking towards your question and anxiety, you need personal counseling where you can express yourself face-to-face. Only after the NEET exam is over, you contact a counsellor for one-to-one counseling. Till then, keep mum and focus only on NEET. Take this exam as your mission and project. Work on this project, apply forces from all sides, success is there which is waiting for you eagerly.
Best of luck for your bright future.

Some tips: (1) Analyse separately Phy, Che, Bio (2) Prepare a list of hard topics (3) First focus more on the topics which are easy for you and then try to excel in hard topics (4) Appear more and more online/offline examinations (4) Prepare your short-cut file for all subjects (5) Prepare a file for each subject having only synopsis of all chapters (6) Try to solve the problems at the lightening speed and observe the period on regular basis (7) Create your time table to revise the topics on regular basis (8) Do not hesitate to ask your difficulties to your teachers, if you have joined to offline classes (9) Keep the habit of marking the answers which you know 100%. Don't guess the answers and mark them, as there is -ve marking scheme. (10) Be calm, quite, and smiling all the time to release the tension and always have a healthy chat with your friends.

If satisfied, please like and follow me.
If dissatisfied with the reply, please ask again without hesitation.
Thanks.

Radheshyam

...Read more

Pradeep

Pradeep Pramanik  |186 Answers  |Ask -

Career And Placement Consultant - Answered on Nov 21, 2024

Listen
Career
I am looking for a job, I had uploaded my resume in job site. A consultant called me & introduced himself telling he know some of the openings. He had a detailed discussion about my job & my skills. He told need to register to his consultancy for scheduling interview. I registered with him & he got me a interview. Interview was done by the company through skype. I could not see the company persons. They told only they can see me. Interview went on well & regarding salary I told my expectation but they told it is not possible & they told their proposal. Finally I agreed to them. They gave me code & told to visit the company for next round. Consultant called me after first round & told recruiter is very happy with the interview. Regarding salary he told why I agreed for the proposal,he will discuss again & asked to pay charges for some of his services which he will refund the day I visit to the company & take the orders. I paid him. He told there is a increase in salary he has discussed with recruiter & again asked for the money I did only partial payment & further will not pay anything. Second round also happened through skype instead of in person. Interview went on well & salary offered was good comparing to before & there was a big jump. Recruiter told they have planned to give additional responsibilities so they have increased. Finally they gave me a date to visit company. I asked when will I get the order, he replied he will send to consultant as I was taken by them. Till now i did not get the orders, consultant is keep on postponing. Now he told visit to company date is also postponed, he will update in next week & not to worry as job is confirmed. Now not understanding what to do, am I been cheated or wait.
Ans: Dear Mr. Keshava ,

There are many unscruplous job agents who are fake and claim themselves to be a Placement consultant. In short You have been cheated . Before paying any fee for registration , you must ensure that the agency is genuine . If not don't even upload your resume . You may write to company , lodge a complaint against the agency. If the amount is very high , pl. take the help of police . .

...Read more

Ramalingam

Ramalingam Kalirajan  |7097 Answers  |Ask -

Mutual Funds, Financial Planning Expert - Answered on Nov 21, 2024

Listen
Money
I hv started sip in 2008 and still continued , now the monthly sip is 55k and total value is 1.85cr. Need to accumulate 7cr with in next 4 yrs pls guide how can i achieve. - Deepak J. Hajari
Ans: Deepak, your long-term SIP discipline is impressive. Accumulating Rs. 7 crore in 4 years is ambitious. Achieving this goal requires a strategic approach, as time is limited. Let's create an actionable plan for your success.

Current Financial Snapshot
Ongoing SIPs: Rs. 55,000 monthly.
Current Portfolio Value: Rs. 1.85 crore.
Target Corpus: Rs. 7 crore within 4 years.
Your consistent investing habits have built a solid foundation. However, to achieve your target, adjustments are needed.

Key Challenges
Short Time Frame: Four years is a limited period for aggressive wealth accumulation.
Significant Gap: A gap of Rs. 5.15 crore remains to meet the Rs. 7 crore goal.
Market Volatility: Equity investments might face short-term volatility.
Recommendations to Bridge the Gap
1. Increase Your SIP Contributions
Raise your SIP amount to Rs. 1.25 lakh per month.
This increase ensures faster wealth creation through compounding.
Prioritise high-growth funds in equity-oriented categories.
2. Invest Lump Sum Amounts
Consider deploying a lump sum if you have idle savings or low-yield investments.
Invest in aggressive equity mutual funds for higher potential returns.
Break down the lump sum into tranches for better market timing.
3. Diversify into High-Growth Mutual Funds
Focus on small-cap and mid-cap mutual funds for higher growth potential.
Maintain a balance with some large-cap exposure for stability.
Ensure the portfolio aligns with your high-return requirements.
4. Avoid Overexposure to Debt or Low-Yield Instruments
Limit debt investments during this aggressive growth phase.
Avoid instruments like FDs or debt mutual funds with lower returns.
Rely on equity for the next four years to maximise growth.
5. Rebalance Your Portfolio Regularly
Conduct a portfolio review every 6 months.
Reallocate funds based on underperforming or outperforming sectors.
Keep your portfolio aligned with market trends and your goals.
6. Capitalize on Bonus or Windfall Gains
Direct any bonuses, salary hikes, or windfall gains towards your target.
Avoid unnecessary expenses during this focused phase.
Tax Efficiency Matters
Equity Mutual Funds Taxation: Gains above Rs. 1.25 lakh are taxed at 12.5%.
Debt Mutual Funds Taxation: Taxed as per your income slab.
Plan redemptions strategically to minimise tax liabilities.
Leverage Market Opportunities
Benefit from Market Corrections: Use corrections as opportunities to invest lump sums.
Stay Invested for Compounding: Avoid early redemptions to let compounding work fully.
Role of Regular Monitoring
Track Performance: Ensure funds are performing as per expectations.
Switch Funds if Needed: Shift from underperforming funds to high-growth options.
Final Insights
Deepak, achieving Rs. 7 crore in 4 years requires aggressive yet calculated strategies. Increase your SIPs, deploy lump sums, and focus on high-growth funds. Regular monitoring and disciplined investing are key to your success. Stay patient and consistent.

Best Regards,

K. Ramalingam, MBA, CFP,

Chief Financial Planner,

www.holisticinvestment.in
https://www.youtube.com/@HolisticInvestment

...Read more

DISCLAIMER: The content of this post by the expert is the personal view of the rediffGURU. Investment in securities market are subject to market risks. Read all the related document carefully before investing. The securities quoted are for illustration only and are not recommendatory. Users are advised to pursue the information provided by the rediffGURU only as a source of information and as a point of reference and to rely on their own judgement when making a decision. RediffGURUS is an intermediary as per India's Information Technology Act.

Close  

You haven't logged in yet. To ask a question, Please Log in below
Login

A verification OTP will be sent to this
Mobile Number / Email

Enter OTP
A 6 digit code has been sent to

Resend OTP in120seconds

Dear User, You have not registered yet. Please register by filling the fields below to get expert answers from our Gurus
Sign up

By signing up, you agree to our
Terms & Conditions and Privacy Policy

Already have an account?

Enter OTP
A 6 digit code has been sent to Mobile

Resend OTP in120seconds

x