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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

Sanjib Jha  | Answer  |Ask -

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.   

..Read more

Sanjib

Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on Sep 08, 2022

Ramalingam

Ramalingam Kalirajan  |6292 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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Dr Karthiyayini

Dr Karthiyayini Mahadevan  |1065 Answers  |Ask -

General Physician - Answered on Sep 14, 2024

Asked by Anonymous - Sep 13, 2024Hindi
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I am 75 + ....Around two months back I was diagnosed as dengue positive with platelet count at 75,000. with proper medication, platelet counts were increased to 2,05,000 and fever was subsided.However swellings on both arms and legs persisted.. Off late on my both solders i am suffering severe pain and enable to make any movement, i feel like inner vain of my both hands are getting stretched/pulled (right from my solder to the finger tips and swelling on both hands and legs are still there. My doctor says that it may continue for another two three months and proscribed me only pain killer tablets.Doctor says that there is no specific medicine for Dengue. I got thorough blood and urine test along with other test like scanning, x-ray etc. All the test reports are normal except slightly blood sugar (PP) on higher side and enlargement of prostate gland (which is there since last 10 years and i am on regular medicine (silodosin 8-mg, one tab a day) Kindly advise me with your good suggestions that what could be the cause of this problem and which expert doctor I should consult since it is very difficult situation for carrying out my routine activities and also I can't sleep properly due to severe pain. Thank you
Ans: Post viral illness can trigger different chain of immune reactions
They are mostly self limiting if your lifestyle is well disciplined.
Here are the points towards a healthy lifestyle
1.Early dinner by 6 pm and avoid animal protein and fat at dinner meal
2.Sleeping time to be regulated. Fix a specific time around 9/9.30 pm and unwind from the world particularly off media from 7 pm
3.Regular brisk walking 30 mts a day five days a week
4.Balanaced nutrition and avoid highly refined carbohydrates

...Read more

Milind

Milind Vadjikar  |132 Answers  |Ask -

Insurance, Stocks, MF, PF Expert - Answered on Sep 14, 2024

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I am going to turn 34 years old this year. Me and my wife earn 3.7 Lakh Per Month In Hand (Post all deductions: Tax, EPF), above included salary and rental. 3 Lakh per month i can invest. How do you suggest i should invest for achieving my goals. In my family i have my Wife, Son 4 YO and my parents. Live with my parents in my own house so i do not plan to buy house. My wife and my own current savings: - 80 lakhs in Equity (PMS and Mutual Funds). - 45 Lakh in Crypto Currency (Invested 5 lakh very early and i want to stay invested). - Commercial Real Estate Office Worth 1 Cr. yielding rental of 47 thousand per month. - 15 Lakh Provident Fund - 20 Lakh Bank FD & Arbitrage Fund (Emergency Fund) - 5 Lakh Savings Account (Day today expenses) Expenses: - 70k per Month including everything (Daily expense, Vacation, mobile etc). - Our monthly expense is low as my father is also working and many other expenses (around 50k) are taken care by him only. I have health insurance cover from my company of 6.5 lakh. Personal medical insurance of 10 lakh. Term insurance from my company of around 1.7 crore. Personal Term Insurance of 4 crore. Zero loans. Goals: - 1.5 crore in today's terms 10-12 years later to reconstruct the house. - 40 lakh, 6 years later for new car. - 3-4 crore at age of around 55 (For my personal goal). - 2 crore for my son higher education. - 30 crore for my retirement.
Ans: Thanks for candidly sharing your goals, current income and savings/investments.

You have adequate term life cover but recommend to cover family and parents with healthcare cover of 50 L as a minimum considering increasing cost of medical treatments and rise in illnesses with age.

Your existing investments are considered as 95 L (Ignoring Emergency fund and saving account balance)

Crypto holdings are considered 0 since they are highly volatile, unregulated and not backed by any tangible asset.

1.5 Cr house reconstruction expenses 12 years hence translates into around 3 Cr considering 6% inflation.

So start a SIP of 90K for 12 years into Nippon India Multicap Fund & HDFC top 100 Fund(50:50)which may yield a corpus of 3.12 Cr(Considering modest return of 13%)

Next goal is car purchase after 6 years so initiate a SIP of 40K in HDFC balanced advantage fund which will yield a corpus of 40L considering modest return of 10.5%

Next goal is a corpus of 3-5 Cr when you will be 55 so you can do a SIP of 50K in PPFAS flexicap fund which will yield a corpus of 5.73 Cr assuming conservative return of 13%

Further important goal is corpus for child education so considering timeframe of 14 years recommend to do a SIP of 50K in HDFC Children's Gift Fund which will yield a corpus of 2Cr+ assuming modest return of 12%

Finally retirement goal of 30Cr assumed to be 25 years from now so you may start a SIP of 70K in ICICI Pru Retirement Fund Pure Equity Plan which yield you a corpus of 15.9 Cr considering modest growth of 13%.
Plus your corpus of 95 L at a modest return of 9.5% will yield a value of 9.18Cr after 25 years
So your total retirement corpus is now 15.9+9.18=25.08 Cr
Further the amount getting released after achievement of all other goals apart from retirement can be redeployed in a value based BAF(HDFC; 10% return) for residual span towards retirement goal.
i.e. 90K for 13 years --2.89 Cr
40K for 19 years--2.73 Cr
50K for 5 years----0.39 Cr
50K for 11 years---1.2 Cr
Total_-----------------------7.21 Cr

Adding this to our earlier calculated retirement corpus gives us comprehensive retirement corpus of 7.21+25.08= 32.21 Cr

Anything you get from Crypto is bonus!!

*Investments in mutual funds are subject to market risks. Please read all scheme related documents carefully before investing

You may follow us on X at @mars_invest for updates

Happy Investing!!

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Ramalingam

Ramalingam Kalirajan  |6292 Answers  |Ask -

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

Asked by Anonymous - Sep 14, 2024Hindi
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I am 27 years old studying 3rd year MD, have the following monthly SIPs. 1.PPF 12500 2. PLI 5300 3. Jeevan Umang 5400 4. RD 4500 5. ICICI equity and debt fund 5000 6. ICICI india oppertunity fund 2000 7. Kotak multi cap fund 2000 8. Sundaram service fund 2000 9. Nippon small cap fund 2000 10. HDFC multi cap fund 2000 11. Canara robaco blue chip equity fund 2000 12. Motilal Oswal large and mid cap 5000 Please evaluate my portfolio and advice Do I need to cancel any of the above Or should I go for alternatives than above mentioned Kindly suggest
Ans: At the age of 27, with a long-term investment horizon, you have built a diverse portfolio. However, a review of your portfolio is necessary to ensure optimal returns and financial security. Let’s assess each of your existing investments while providing insights on potential improvements.

1. PPF (Public Provident Fund)

The PPF is a solid choice for risk-free, tax-efficient, long-term savings.

It offers guaranteed returns and tax benefits under Section 80C.
It should be continued as part of your debt allocation.
However, you may want to limit over-reliance on low-return instruments like PPF, as it has a lock-in period of 15 years and a lower growth potential compared to equities.
2. Postal Life Insurance (PLI)

PLI is one of the oldest and most reliable life insurance products in India.

It offers low premiums with high returns.
However, if you are purely looking for life cover, term insurance may offer a higher sum assured at a lower cost.
For wealth accumulation, this may not be the most optimal choice due to its moderate returns. It is advisable to review whether you need both PLI and Jeevan Umang (discussed below).
3. Jeevan Umang

Jeevan Umang is a combination of life insurance and investment, providing regular payouts.

Such investment-cum-insurance plans generally offer lower returns compared to mutual funds.
You might want to re-evaluate keeping this plan since standalone life insurance (term insurance) combined with mutual fund investments may provide better growth and flexibility.
Cancelling or surrendering this policy should be considered after evaluating its surrender value and whether it's feasible based on your financial goals.
4. Recurring Deposit (RD)

RDs are low-risk instruments but have relatively lower returns.

While RDs ensure capital safety, they might not be ideal for wealth creation, especially for long-term goals.
Since you're still young with a long investment horizon, it might be better to channel more funds into equities for higher growth potential.
Consider reducing or stopping this RD and redirecting the funds into equity-based investments.
5. ICICI Equity and Debt Fund

This hybrid fund is a balanced option offering exposure to both equity and debt.

It provides the potential for growth through equities while managing volatility with debt.
As you are young and have a long-term horizon, a higher allocation towards pure equity funds might yield better long-term results.
Evaluate whether you need a hybrid fund in your portfolio, as your other debt investments (PPF, RD) already provide stability.
6. ICICI India Opportunity Fund

This is a thematic fund, focused on certain sectors or market opportunities.

Thematic funds can be more volatile and risky compared to diversified equity funds.
Consider whether you need exposure to such a niche strategy. These funds can work well in a bull market but may not be ideal for consistent long-term growth.
It might be wiser to replace this fund with a more diversified equity mutual fund for better stability.
7. Kotak Multi Cap Fund

Multi-cap funds invest across large-cap, mid-cap, and small-cap stocks.

Multi-cap funds are suitable for long-term growth as they provide diversification across different market capitalisations.
This is a good choice to hold as it balances risk and returns by spreading investments across different categories.
No change is required here.
8. Sundaram Service Fund

Thematic funds like this one tend to focus on specific industries or sectors.

Sector-focused funds are prone to higher volatility due to limited diversification.
While such funds can provide high returns in specific cycles, they may not be ideal for consistent long-term growth.
You could consider switching to a diversified equity fund to reduce concentration risk.
9. Nippon Small Cap Fund

Small-cap funds have high growth potential but are also volatile.

Given your long-term horizon, small-cap funds can offer excellent growth opportunities.
However, small-cap funds should be a part of your portfolio, but with a smaller allocation due to higher risks.
Keep an eye on the fund’s performance and market conditions but maintain some exposure to small caps for aggressive growth.
10. HDFC Multi Cap Fund

Similar to the Kotak Multi Cap Fund, this fund offers broad exposure across different types of companies.

Multi-cap funds are an important component of a well-diversified portfolio.
Holding multiple multi-cap funds may lead to overlapping stock investments, so it may be beneficial to consolidate into one multi-cap fund for simplicity and efficiency.
No immediate need for cancellation, but consider streamlining your investments.
11. Canara Robeco Blue Chip Equity Fund

Blue chip equity funds invest in well-established companies with strong track records.

Blue chip funds are a stable option for long-term wealth creation with moderate risk.
These funds tend to perform well in the long term, providing stable growth.
Continue investing in blue-chip equity for consistent, lower-risk returns.
12. Motilal Oswal Large and Mid Cap Fund

This fund invests in a mix of large and mid-cap companies.

Large and mid-cap funds offer a balance of stability from large caps and growth potential from mid caps.
It’s a good choice to keep, given your long-term investment horizon.
Continue your SIP in this fund as it provides a diversified exposure to both stable and high-growth companies.
Portfolio Insights

Your portfolio is a mix of both equity and debt instruments. There are areas where you could improve efficiency and focus more on growth. Since you are young, your portfolio should focus more on equity investments rather than debt or conservative instruments.

Here are some points for improvement:

Consider reducing or stopping PLI, Jeevan Umang, and RD. They offer lower returns and are not ideal for wealth accumulation.
Consolidate your multi-cap funds to avoid redundancy and improve efficiency.
Consider moving away from thematic funds (ICICI India Opportunity, Sundaram Service) and replace them with more diversified options for better risk management.
Maintain small exposure to small-cap funds but don’t over-allocate due to volatility.
Large-cap and blue-chip funds should continue, as they provide stability to your portfolio.
Investment Strategy Moving Forward

Since you are currently pursuing your MD, you might want to focus on building a strong long-term growth portfolio. The following strategy could help you optimise your investments:

Increase Equity Exposure: Given your young age and long-term goals, you could increase your equity exposure to maximise returns. Equity mutual funds have historically outperformed other asset classes over long periods.

Reduce Debt Instruments: PPF is a good debt instrument, but the RD and life insurance policies may not be ideal for wealth creation. Consider directing those funds into more growth-oriented investments.

Review Insurance Needs: If your current life insurance policies are not providing adequate coverage, switch to a term plan that offers high coverage at a lower premium. This will allow you to free up more funds for investment purposes.

Consolidate and Simplify: You have multiple schemes in similar categories, which might lead to unnecessary overlap. Streamlining your portfolio by focusing on a few high-quality funds can make it easier to track performance.

Continue SIPs: SIPs are a great way to invest systematically. Increase your SIPs in funds with strong performance records and reduce exposure to underperforming or high-risk funds.

Monitor Portfolio Regularly: Keep track of your fund performance, rebalance annually, and make adjustments as needed to align with your goals.

Final Insights

Your portfolio is already in a good shape for someone at the start of their professional career. However, there are some areas where you could optimise for better returns. By focusing more on equity and less on conservative products like life insurance and RDs, you can enhance your wealth creation potential.

This shift in strategy will allow you to focus on long-term growth, ensuring a solid financial foundation for the future.

Best Regards,

K. Ramalingam, MBA, CFP,

Chief Financial Planner,

www.holisticinvestment.in

...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.

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