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Tata AIG Mediclaim: What to Do When Claim Denied?

Ramalingam Kalirajan |7367 Answers |Ask -Follow

Mutual Funds, Financial Planning Expert - Answered on Aug 07, 2024

Ramalingam Kalirajan has over 23 years of experience in mutual funds and financial planning.
He has an MBA in finance from the University of Madras and is a certified financial planner.
He is the director and chief financial planner at Holistic Investment, a Chennai-based firm that offers financial planning and wealth management advice.... more

Question by Bharat on Aug 07, 2024Hindi

I have tataaig mediclaim before one year I claimed 55000+ rs. But after two month only 48000+ rs. pass and other 7000+ rs. Which are purely doctor fees and medicine are not given i already sent duplicate or Xerox as per requirement but now days they want original document which are i submitted at very first time and everytime they want original document so now what to do ?

Ans: You claimed Rs. 55,000+ from Tata AIG mediclaim.
They approved Rs. 48,000+ after two months.
Rs. 7,000+ for doctor fees and medicines not approved.

Document Submission

You've sent duplicate or xerox copies as asked.
Now they're asking for original documents again.
You've already submitted originals at the start.

Common Insurance Practice

Insurers usually keep original documents for approved claims.
They might return originals for rejected parts of claims.
It's unusual to ask for originals repeatedly.

Possible Steps to Take

Call Tata AIG customer care for clarification.
Ask why they need originals you've already submitted.
Request them to check their records for your documents.

Escalation Process

If customer care doesn't help, escalate to grievance cell.
Write a formal complaint to Tata AIG's grievance officer.
Clearly explain the timeline of your document submissions.

Document Trail

Gather proof of all your document submissions.
This includes courier receipts or acknowledgement emails.
These can support your case if you need to complain.

IRDAI Complaint

If Tata AIG doesn't respond, complain to IRDAI.
IRDAI is the insurance regulator in India.
They can intervene if the insurer is being unreasonable.

Future Precautions

Always keep copies of all documents you submit.
Get acknowledgement for document submissions from the insurer.
Follow up regularly on your claim status.

Medical Records

Ask your doctor for duplicate prescriptions if possible.
Get copies of medical records from the hospital.
These might help if you can't provide the originals again.

Time Limit

Check your policy for claim settlement time limits.
Insurers usually have to settle claims within 30 days.
Delays beyond this can be reported to IRDAI.

Finally

Stay patient but persistent in following up.
Keep all communication with the insurer in writing.
Consider seeking help from a Certified Financial Planner for guidance.

Best Regards,
K. Ramalingam, MBA, CFP,
Chief Financial Planner,
www.holisticinvestment.in

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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Question by S - Jun 21, 2022Hindi

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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