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Sanjib

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Insurance Expert - Answered on Jul 28, 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
Anoop Question by Anoop on Jul 28, 2022Hindi
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My Oriental Mediclaim coverage is for Rs 5 lakh under Royal Mediclaim cashless scheme vide PNB. I have completed 36 months, a conditional requirement (a facility only for PNB customer).

In this regard I have a few questions...

Ans: Hi Anoop, thanks for sharing your queries, will take them one by one.

1. What's the meaning of 5 lakh coverage? Will I get a full 4.95 lakh for both knees transplant (my hospital package is costing 4.95 lakh from entry to exit)?

Sanjib Jha:  A coverage of 5 Lakh means your policy covers you up to 5 lakh and you can claim it. However, the coverage amount for knee transplant depends on insurer to insurer as few of the policies having certain capping on the coverage amount for such treatments.

2. When the hospital sent the proposal to TPA, only 2.47 lakh were provisional sanction. What's the meaning of provisional? I was told that the final amount will be settled once final bill is produced by the hospital. Does it mean that 4.9-2.47=2.43 lakh or so, will be settled and remitted to the hospital by Oriental insurance? 

Provisional Sanction amount is the amount that the insurer approves based on the ailment i.e., knee transplant in your case. The rest of the amount approval is provided based on the final bill generated by the hospital.

3. When I sought clarification from TPA, I was verbally told that now the final amount cannot be decided. Only after the final bill it can be. Nothing said on email. No replies from Oriental insurance of my email query.

For policies issued by Oriental, the claims are handled by TPA (Third Party Administrator). I advise you to raise the concerns to TPA via email or via TPA desk to get the clarification. Also, the insurer can provide the final approval after the final bill is generated by the insurer, deducting the non-approved cost as per policy terms & condition.

4. Hospital insists that I deposit 50% (2.5 lakh) cash from pocket before admission.

As it seems that the insurer has provided pre-approval for 2.47 lakh, the rest amount you will have pay to the hospital & the same will get approved by the insurer once the final bill is generated by the hospital.

5. If I have to pay cash, then where is the cashless scheme?

I advise you to check the terms of your policy. Often certain treatments are not covered in particular policies, which is why it is extremely important to read your policy document thoroughly and ask all your queries to the agent/Insurer before purchase. For specific ailments, there are add-ons offered by insurers and accordingly one should opt for those add-ons.

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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I read your today's article about Mediclaim: What You Must Know. Thank you for some important information and points shared. I have some questions about the Mediclaim policy. I have been buying a Mediclaim policy since 2007 and I have not claimed it till last month. Last week I was hospitalized for gall bladder stone surgery. When I asked the hospital to use the cashless option on my Mediclaim policy for claims they gave an estimated cost of about 1 lakh. And same if I claim myself, they gave an estimated cost near about 55 thousand.  1. Why and what is the difference between these charges? How did the TPA approve cashless? Is there any guideline or standard process for hospitals that can claim more charges in cashless options? 2. Why do cashless charge more? Due to this type of charges for cashless claims the sum insured amount decreases after treatment. We can utilise the same difference charges amount for another treatment.
Ans: Hi Vilas, in order to understand the difference in the estimated costs, you should ask the hospital on what parameters they have estimated the two costs. Questions on treatment protocol, room charges and type, doctor’s fee etc., should be asked.

When choosing cashless treatment, the patients often opt for the best facilities that they may not have opted for otherwise. Sometimes hospitals may run some additional tests as well in order to avoid back and forth on your claim settlements, when it is a direct transaction between insurer and the hospital.

However, if you feel that you are being overcharged, then you should report any discrepancy in what you are being charged for, to the insurer. Insurance companies take such cases very seriously, which is why insurers have preferred network hospitals that agree on a certain pricing for various treatments and other tariffs.

In case it is observed that there is any abuse of cost or sum insured then there is a chance of being de-paneled and hence a check is in place.

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Sanjib

Sanjib Jha  | Answer  |Ask -

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This is Bobby here and have a few questions related to your article (enclosed), Mediclaim: What You Must Know Would like to know, with your experience in this field, as to: 1. Which mediclaim policy or policies, currently in INDIA and especially Mumbai has all the required coverage as mentioned in your article 2. We are a family of 3 with a school going child and both of us are aged 45 3. Have acquired diabetes a few months ago and have hepatitis B and kidney stones  4. What should be the approximate premium, per annum to cover all that is mentioned in your article and keep us safe from the issues arising out if and when we really require hospitalisation and save us from rejected claims.   5. Presently we are covered under Mediclaim policy from Star Health Would be highly obliged should you guide us on the above to make our lives easier.
Ans: Hi Bhupesh, there is no ‘one size fits all’ concept with health insurance. Health insurance is based on preferences of the customer and then the premium quotes are generated based on those factors. You can use insurance broking websites to compare the offerings on the mentioned 5 factors and the premiums for various policies that will help you to compare their benefits and make an informed choice. Depending on your priorities, weigh out the factors and decide accordingly.

Since you have mentioned about your family, you can opt for Family Health Insurance policies with an appropriate sum insured to cover your entire family. Like I have mentioned before, premiums are unique to individuals depending on their preferences, the sum insured they deem suitable, the riders they choose, their medical history etc.

What you can do to ensure you buy the correct policy for yourself is to evaluate policies carefully, keeping in mind the 5 important parameters.

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I have mediclaim policy from Oriental Insurance Co since 1992 for 5 lakhs and other from New India Assurance for 7.5 Lakhs under SCUM scheme with my spouse. However both the policies have set a limit of Rs. 40,000 for Cataract surgery even though I have been diagnosed with 1) Cataract Phaco with Panoptix IOL, 2) Pupilloplasty, 3) CTR Implantation for which a renowned hospital billed me as below for separately for each eye. 1) Cataract Procedure Cost. Rs. 27000/- which is approved by Oriental in their contract with Hospital 2) IOL Cost Rs. 49000/- 3) Pulilloplasty Rs. 6950/- after discount 4) CTR Implantation Rs. 1600/ after discount Now in Claim No. 1 Oriental approved. Rs 36,000/- Only and balance Rs 48500 I had to pay Claim No. 2 Oriental approved Rs.73,300/- Only and balance Rs.11250/- I had to pay Surgery was done 1 week apart. In my case I was advised Cataract with multifocal IOL + Pupilloplasty + CTR Implantation So, I need your advice on: How can Insurer Oriental approve and give different claim amount for each eye and how can I claim for reimbursement of balance amount I had to pay. Appreciate your guidance and help.
Ans: Hi Jyoti, hope you are doing well. As you have mentioned that the claim amount for each eye has been different, to understand the reason behind this disparity, you will have to check the documentation submitted to the insurer for both the surgeries. Request you to contact your insurance advisor and discuss the same with the insurer to understand this gap further and help you resolve this issue. 

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Hi, i have completed my masters in food technology and want to work as freelancers as a auditor in food industry could you guide how to go about doing.
Ans: Transitioning to freelance work as a food industry auditor can offer you flexibility and autonomy in your career. Evaluate your qualifications, experience, and skills in food technology, quality assurance, and auditing. Identify areas where you have expertise and experience that are valuable to potential clients in the food industry. Familiarize yourself with the requirements and standards for food auditing, including regulatory requirements, industry standards (such as ISO 22000, HACCP), and customer specifications. Understand the auditing process, documentation requirements, and audit protocols. Consider obtaining relevant certifications or training in food safety auditing, such as Certified Food Safety Auditor (CFSA), Lead Auditor Training, or other accredited programs. These credentials can enhance your credibility and qualifications as a freelancer. Network with professionals in the food industry, including food manufacturers, suppliers, distributors, and regulatory agencies. Attend industry conferences, seminars, and networking events to connect with potential clients and collaborators. Determine the specific services you will offer as a food industry auditor, such as food safety audits, quality management system audits, regulatory compliance assessments, or supplier audits. Identify your target market, including food manufacturers, processors, retailers, or food service providers. Develop a professional brand identity for your freelance auditing services, including a business name, logo, website, and marketing materials. Highlight your expertise, qualifications, and unique value proposition to attract potential clients. Determine your pricing structure based on factors such as the complexity of audits, scope of services, and industry standards. Establish clear policies regarding payment terms, project timelines, and confidentiality agreements to protect both your interests and those of your clients. Promote your freelance auditing services through online channels, social media platforms, industry forums, and professional associations. Create content related to food safety, quality assurance, and auditing best practices to showcase your expertise and attract potential clients. Cultivate relationships with potential clients by offering value-added services, such as training, consulting, or ongoing support. Build trust and credibility through transparent communication, professional conduct, and delivering high-quality audit reports and recommendations. Establish systems and processes for managing your freelance business, including client communication, project management, invoicing, and record-keeping. Prioritize time management and organization to balance your freelance work effectively. 

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I retired earlier now at 53. Invested 7L in ELSS and using 60L on short term equity trading (with monthly average gain 2L) and having own apartment home worth 40L. Having dependent widowed mother, wife with 13 yrs old daughter. Intended to raise daughter as doctor. Please suggest better investment options.
Ans: Congratulations on your early retirement! It sounds like you've made some good initial decisions, but there's definitely room for improvement to secure your family's future, especially considering your dependents. Here's how you can optimize your investments:

Reduce Risk in Short-Term Equity Trading:

While a ?2 lakh monthly gain from short-term trading sounds impressive, it's a very risky strategy. The market can be volatile, and these gains may not be sustainable. Consider allocating a much smaller portion (maybe 10-20%) to short-term trading and focus on more stable options for the majority of your investable assets (?60 lakh currently in trading).
Focus on Long-Term Growth and Stability:

Increase Investment in ELSS: ?7 lakh is a good start, but for your daughter's education and your retirement needs, you'll likely need a much larger corpus. Consider increasing your SIP amount in ELSS or similar diversified equity mutual funds with a long-term horizon (10+ years).
Explore Debt Options for Regular Income:

You mentioned having a dependent mother and daughter's education to plan for. Consider investing a portion (maybe 20-30%) of your investable amount in safer debt options like Public Provident Fund (PPF), Senior Citizen Savings Scheme (SCSS) for your mother (if she's above 60), or fixed deposits to generate a regular income stream.
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Doctorate studies can be expensive. Start an SIP in a dedicated child education plan or invest in aggressive equity funds specifically for this goal. Talk to a Certfied Financial Planner for personalized recommendations based on the estimated cost of medical education.
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Dear Sir My age is 34 yrs. I have working alredy 10 yrs and my average total income till date 40L minimum. Still I did not save 1rs till now. Request you please advice how to start savings also make future retirement plan. My expected retirement age is 55yrs.
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Track your expenses: For a month, track where your money goes. This will help identify areas to cut back and free up savings.
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Automated savings: Set up a Systematic Investment Plan (SIP) in a mutual fund. Start small, even with ?1,000 per month, and gradually increase as you get comfortable.
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You mentioned an average annual income of ?40 lakhs. Aim to save at least 10-15% of your income, which translates to ?4,000-?6,000 per month.
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Hello Sir, I'm 45 years old investing for retirement corpus and plan early retirement at 55. Below is my portfolio and current value-23 lacs 1.Nippon small cap 2.quant ELSS 3.Kotak flexicap 4.UTI nifty 50 index-new 5.Motill Oswal midcap150 index-new 6.HSBC midcap am doing a sip of 50k-is it enough? to reach Target of 1 crore in 10 years.
Ans: It's fantastic that you're already thinking about retirement at 45. Life has a way of whizzing by, doesn't it? Having a 10-year plan towards a ?1 crore corpus for early retirement at 55 shows real foresight.

Now, looking at your portfolio with a mix of large, mid, and small-cap funds, it's clear you've diversified across market capitalizations. That's a smart approach! But with a goal ten years down the line, have you considered how much risk you're comfortable with? Remember, the ride might get bumpy closer to retirement, and you might want to consider a chat with a Certified Financial Planner (CFP). They can help you fine-tune your asset allocation to balance growth potential with stability as you near your retirement mark. Think of it like planning a trek to the Himalayas – you want the right gear for every stage of the climb!
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I am 62 years old healthy person having more then 30 years experience in commercial field I want a job. Is it is possible to get job anywhere in this age.
Ans: Yes, it is possible to find employment opportunities at any age, including 62 years old. While some employers may have preferences for younger candidates, many organizations value the experience, wisdom, and expertise that mature professionals bring to the table. Leverage your professional network and connections to explore job opportunities, gather insights, and seek referrals. Attend industry events, networking mixers, and professional association meetings to expand your network and connect with potential employers or recruiters. Be open to flexible work arrangements, such as part-time roles, consulting opportunities, contract work, or project-based assignments. Many companies are willing to hire experienced professionals on a flexible basis to leverage their expertise without committing to full-time employment. Research companies or industries that value and prioritize experienced professionals. Look for organizations known for their inclusive workplace cultures, diversity initiatives, and appreciation of older workers' contributions. Customize your job search approach to align with your career goals, preferences, and lifestyle. Focus on opportunities that match your skills, interests, and desired work environment, whether it's a small business, a nonprofit organization, or a corporate enterprise. Approach your job search with confidence, positivity, and enthusiasm. Highlight your unique strengths, accomplishments, and value proposition to prospective employers, and convey your eagerness to contribute and make a difference in a new role.

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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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