Why do third party agents hesitate to reimburse genuine health expenditure incurred on ayurvedic treatment {all conditions fulfilled including admission in ayurvedic hospital}. All proofs submitted. What should I do if the TPAs don't process my claims for ayurvedic treatment?

Ans: There are a few reasons why third party administrators (TPAs) might hesitate to reimburse genuine health expenditure incurred on Ayurvedic treatment, even if all conditions are fulfilled and proofs are submitted.

• Ayurveda is not mainstream medicine: While Ayurveda is an ancient and recognised form of medicine in India, it is not considered mainstream medicine by some insurance companies. This means that TPA might not have clear guidelines for processing and approving Ayurvedic treatment claims.
• Lack of standardisation: There can be a lack of standardisation in Ayurvedic practices and treatments. This can make it difficult for TPAs to assess the validity and legitimacy of a claim.
• Cost-containment: TPAs work for insurance companies, and insurance companies are in the business of making money. This means they may be looking for reasons to deny or delay claims. Ayurvedic treatments can sometimes be expensive, and TPAs may be looking for ways to control costs.

Here are some things you can do if your TPA is not processing your claims for Ayurvedic treatment:

• Review your policy documents: Carefully read your insurance policy documents to understand the coverage for Ayurvedic treatment. Look for exclusions or limitations that might apply.
• Contact your TPA: Call your TPA's customer care department and ask them to explain why your claim was denied. Be polite but persistent in getting answers.
• File an appeal: If you are not satisfied with the TPA's explanation, you can file an appeal. The appeal process will vary depending on your TPA, but there should be information on how to file an appeal in your policy documents or on the TPA's website.
• Contact your insurance company: If the appeal process is unsuccessful, you can contact your insurance company directly. Explain the situation and ask them to intervene on your behalf.
• Consider legal action: If all else fails, you may want to consider taking legal action against your TPA or insurance company. This should be a last resort, as legal action can be expensive and time-consuming.

Here are some resources that you may find helpful:

• The Insurance Regulatory and Development Authority of India (IRDAI) is the regulatory body for the insurance sector in India. The IRDAI website has information on filing complaints against insurance companies and TPAs https://irdai.gov.in/.
• The Consumer Affairs Department of the Government of India also has a website where you can file complaints against companies https://consumerhelpline.gov.in/.