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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
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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.
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Sanjib

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Insurance Expert - Answered on Jun 21, 2022

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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

Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on Sep 08, 2022

Ramalingam

Ramalingam Kalirajan  |4660 Answers  |Ask -

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

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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.

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Ramalingam

Ramalingam Kalirajan  |4660 Answers  |Ask -

Mutual Funds, Financial Planning Expert - Answered on Jul 14, 2024

Asked by Anonymous - Jul 14, 2024Hindi
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I am 37 years old and a govt servant.i just recently started sip in four funds 1.Mirae asset large and midcap fund direct growth. _1k 2.quant large and mid cap fund direct growth_1k 3.kotak equity opportunities fund direct growth_1k 4.icici prudential retirement fund pure equity plan direct growth -5k Is it good for a term like 10 years?and if i want to invest 5k more then where should i invest for a term of 15 to 20 years.please advice .thank you
Ans: As a government servant at 37, planning for the future is crucial. Starting SIPs in mutual funds is a wise step, but evaluating and refining your strategy can optimize your returns. This analysis will guide you through your current investments and suggest additional avenues for a long-term horizon.

Current SIP Analysis

You've begun SIPs in four mutual funds with a 10-year perspective:

Mirae Asset Large and Midcap Fund
Quant Large and Midcap Fund
Kotak Equity Opportunities Fund
ICICI Prudential Retirement Fund Pure Equity Plan
Your current allocation in these funds is commendable. Let's evaluate the benefits and potential improvements.

1. Mirae Asset Large and Midcap Fund

This fund invests in both large and midcap stocks. It offers growth potential from midcaps and stability from large caps. This balanced approach can yield good returns over the long term.

2. Quant Large and Midcap Fund

Similar to the Mirae Asset Fund, this fund also diversifies between large and midcap stocks. Diversification is a key strategy to mitigate risk while aiming for growth.

3. Kotak Equity Opportunities Fund

This fund focuses on equity opportunities across market caps. It's known for good management and consistent performance. It adds diversity to your portfolio.

4. ICICI Prudential Retirement Fund Pure Equity Plan

This fund is designed for long-term goals like retirement. It invests primarily in equities, which can offer higher returns over an extended period.

Your portfolio currently has a good mix of large-cap stability and mid-cap growth potential. However, since you're considering a long-term investment horizon of 15-20 years, let's explore where you can invest an additional Rs 5,000 per month.

Evaluating Direct Funds vs Regular Funds

You've invested in direct plans, which typically have lower expense ratios. However, regular funds through a Certified Financial Planner (CFP) have their advantages. A CFP provides personalized advice, timely reviews, and adjustments to your portfolio. These services can potentially enhance your investment performance, justifying the slightly higher expense ratios.

Long-term Investment Strategy

For a long-term investment horizon of 15-20 years, consider the following factors:

Diversification: Spread investments across different asset classes and sectors.
Risk Tolerance: Understand your risk appetite and invest accordingly.
Consistent Review: Regularly review and adjust your portfolio based on market conditions and personal goals.
Recommended Investment Avenues

To invest an additional Rs 5,000 per month, here are some funds and strategies to consider:

1. Flexi Cap Funds

Flexi cap funds invest in stocks across market capitalizations. They offer flexibility to shift investments between large, mid, and small caps based on market conditions. This dynamic allocation can capture opportunities across the spectrum and provide robust returns over the long term.

2. Mid Cap Funds

Mid cap funds focus on medium-sized companies with high growth potential. These companies often grow faster than large caps and can offer higher returns. However, they come with higher risk, suitable for a long-term horizon.

3. Sectoral or Thematic Funds

These funds invest in specific sectors like technology, healthcare, or financial services. Investing in a growing sector can yield substantial returns. However, they are riskier and require careful selection and timing. For example, the healthcare sector in India is poised for significant growth due to increasing health awareness and spending.

4. International Funds

Investing in international funds provides exposure to global markets. This diversification can reduce risk associated with the Indian market. It also allows you to capitalize on the growth of developed economies and emerging markets. For instance, a fund investing in US technology stocks can offer high growth potential.

5. Balanced or Hybrid Funds

Balanced funds invest in both equity and debt instruments. They provide growth potential with equity and stability with debt. This mix can be suitable for moderate risk tolerance and long-term investment. These funds can provide a cushion during market volatility, ensuring smoother returns.

6. Multi-Asset Funds

Multi-asset funds diversify across various asset classes, including equity, debt, and gold. This diversification reduces risk and can provide steady returns. Investing in multiple assets helps in balancing the portfolio against market fluctuations.

The Benefits of Actively Managed Funds

While index funds passively track market indices, actively managed funds have fund managers making strategic decisions. Actively managed funds aim to outperform the market, providing higher returns. They adjust portfolios based on market trends, economic conditions, and company performance. This active management justifies the slightly higher expense ratios, as it can potentially lead to better returns than passive funds.

Implementing the Strategy

Based on the analysis, here's a suggested allocation for your additional Rs 5,000 investment:

Flexi Cap Fund: Rs 1,500
Mid Cap Fund: Rs 1,000
Sectoral/Thematic Fund: Rs 1,000
International Fund: Rs 1,000
Multi-Asset Fund: Rs 500
This allocation provides a balanced mix of growth potential and risk mitigation.

Regular Review and Adjustment

Investing is not a one-time activity. Regularly review your portfolio to ensure it aligns with your goals. A Certified Financial Planner can assist in this process, providing insights and adjustments based on market trends and your evolving financial situation.

Final Insights

Investing for the long term requires a strategic approach. Your current SIPs are a good start, and with the additional Rs 5,000 investment, you can further strengthen your portfolio. Diversification across different asset classes and sectors is key to maximizing returns and minimizing risk.

Consider the benefits of regular funds through a Certified Financial Planner. While they have higher expense ratios, the personalized advice and active management can enhance your investment performance.

Focus on a balanced mix of flexi cap, mid cap, sectoral/thematic, international, and multi-asset funds. This diversified approach can capture growth opportunities across markets and sectors, ensuring a robust and resilient portfolio.

Regularly review your investments, adjust based on performance and market conditions, and stay committed to your long-term goals. With careful planning and strategic investments, you can build a substantial corpus for your future needs.

Best Regards,

K. Ramalingam, MBA, CFP

Chief Financial Planner

www.holisticinvestment.in

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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.

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