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Sanjib

Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on May 10, 2023

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
Satish Question by Satish on May 04, 2023Translate
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One of my relatives who had health insurance incurred huge medical expenses year after year, but the insurance company reimbursed whatever coverage was there during the date of admission period. The medical expenses incurred in the following year was denied on the grounds that it could be claimed in the previous year when the patient was admitted, but the insured amount under the policy has exhausted. I seek your as to why it cannot be claimed in the following year as the insurance policy has been renewed. What does the insurance act states.

Ans: Hi Satish, health insurance has to be claimed in the year when the medical expenses were incurred. If the base policy coverage for that year's expense is exhausted and there is no top up plan in support to base policy, then the claim settlement will become an issue as the limit is over. It cannot be adjusted in the next year.
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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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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Dear sir, I am currently 45 and just off from my dependents i.e., my 3 sisters out of which 2 were expecting my help to settle on their life - both my sisters off from their burden to an extent as their son started working and daughters were married to a decent families. I helped them by helping on their studies, marriage of my niece and assisted my nephew to buy a property (provided the advance or initial payment of 4 lacs). I haven't saved anything for my kids yet except a house , some jewellery about 50 sovereign and 1/2 ground land. My sisters and mother doesn't feel complete but I have informed it is not happening because I need to looks at my 2 kids 11 and 6. Besides, my wife is super supportive and never disputes or raised concerns. The ask is I have been working since childhood like 16 so feeling tired at times so I am planning to start my own businesses but still I am feeling jittery as I didn't save much for their studies etc. I am working in ites services so I feel like that I have 5 years max ahead. No politics in the office but I am stuck with no major opportunities. Please guide me on how to put a perspective and lead a clear way ahead as I am totally confused to be honest. Thanks in advance and please write back as this is my second time asking for suggestions.
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