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 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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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.   

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.

Ans: Hello;

Please approach following, in the given order, for redressal of your concern:
1. Customer Relationship Manager of the Insurance company
2. Chief Grievance/Compliance Officer of the insurance company
3. Insurance Ombudsman
4. IRDAI
5. Courts

You may also seek help from some social media activists who take up such cases.

Best wishes;