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Financial Planner - Answered on Mar 18, 2024

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Asked by Anonymous - Mar 17, 2024Hindi
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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/.
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

Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on Jun 21, 2022

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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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Ramalingam

Ramalingam Kalirajan  |10872 Answers  |Ask -

Mutual Funds, Financial Planning Expert - Answered on Apr 05, 2024

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My father is 89 years old and has recurring abdominal pain from last few months. In Apr'23 he was admitted in one private hospital at our locality and admitted for 7 days due to the pain issue. Various tests were conducted including blood tests, CT scan, fibroscopy and endoscopy, no major issues observed except some liver irregularities and discharged after providing certain oral medication. The cashless benefits are obtained through corporate TPA (EWA). However after certain weeks intermittently severe pain recur for almost a week and this time, on first week of July, my father was taken to Kolkata at a hospital specific to liver and digestive treatment. As advised by doctor he was admitted and again various tests are conducted including blood and stool culture, LFT, CT scan and colonoscopy..But this time also no major issues observed and he was discharged after certain medications, which differs from earlier hospital medicines. But this time claim is denied by TPA (EWA) stating that the admission is done only for investigation and observations and no line of treatment was done.. although new medicines are prescribed in the discharge summary and along with that IV fluid and some other medicines were regularly given during his stay in hospital. As TPA has denied the claim, I have to pay the entire amount in spite of paying a hefty amount of premium for my father. Can you pls suggest, why the claim is denied and whether there is any possibility of reimbursement of the claim by any means?
Ans: I'm sorry to hear about your father's health issues and the challenges you're facing with the insurance claim. The denial of the claim by the TPA (Third Party Administrator) could be due to several reasons, including discrepancies in documentation, interpretation of policy terms, or classification of the treatment as investigational rather than therapeutic.

To address this issue and explore the possibility of reimbursement, here are some steps you can take:

Review Policy Documents: Carefully review the terms and conditions of your father's health insurance policy to understand the coverage and exclusions. Pay attention to the criteria for claim eligibility and the definition of covered treatments.

Seek Clarification: Contact the TPA or the insurance provider to seek clarification on why the claim was denied. Request detailed information on the specific reasons for denial and ask for clarification on any policy terms that are unclear.

Gather Documentation: Gather all relevant medical records, including discharge summaries, prescription details, invoices, and receipts for medications and treatments provided during the hospital stay. Ensure that the documentation clearly demonstrates the medical necessity and therapeutic nature of the treatment received.

Appeal the Decision: If you believe that the denial was incorrect or unjustified, consider filing an appeal with the insurance company. Provide supporting documentation and any additional information that may strengthen your case for claim reimbursement. Follow the appeal process outlined by the insurance provider and submit the appeal within the specified timeframe.

Consult an Expert: If necessary, consider seeking assistance from a healthcare advocate or insurance specialist who can help navigate the appeals process and advocate on your behalf. They may offer valuable insights and assistance in presenting your case effectively.

Explore Legal Options: If all attempts to resolve the issue through the appeals process are unsuccessful, you may consider seeking legal advice to explore further options, such as mediation or legal action, to resolve the dispute.

It's important to remain persistent and proactive in pursuing reimbursement for legitimate medical expenses. Keep thorough records of all communications and documentation related to the claim, and continue to advocate for your father's rights as a policyholder.

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Milind

Milind Vadjikar  | Answer  |Ask -

Insurance, Stocks, MF, PF Expert - Answered on Mar 17, 2025

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Sir need clarification regarding 1.i have done Reliance health infinity insurance for 15 lacks .date of inception is 11-6-2020 PEDs not disclosed ( DM,Hypothyroidism)( done by agent not verified me at that time) 2. Did Reliance Super top up policy after 11-7-2022 online by Reliance agent during this i disclosed that PEDs (DM,Hypothyroidism) and at that time specifically mentioned to online agent regarding PEDs and also told him to PEDs not mentioned in base policy please correct it. I never utilised insurance policy for any claims. During 23-4-24 i diagnosed to have Acute Myeloid Leukemia for which i applied for cashless admission for Reliance health infinity insurance ( base policy) They simply rejected on the basis of PEDs not disclosed. And told that your policy is canceled. But i kept a letter to company stating that in base policy PEDs not disclosed, but in super top up policy i mentioned Again the base policy renewal done after expiry by company online. Later also i went for cashless admission again they rejected claim for base policy. My question is why they did renewal of that base policy inspite of first rejection. And for super top up policy it can be claimed after spending 15 lacks i applied for cashless, they processed it and told to come for reimbursement claim After discharge i applied for reimbursement claim they simply replied that your PEDs not told correct duration since how many days. So we are rejecting this policy also For this what should i do, please Ag
Ans: Hello;

In any insurance adequate disclosure is essential to get a thorough underwriting check and risk acceptance.

Once insurance company agrees to insure with the disclosures then chances of claim rejection are remote.

You may escalate the matter with Compliance Officer of the insurance company, insurance ombudsman or IRDAI for an amicable settlement, if possible.

You may also check with organisations such as "beshak.org" for any possible help in the matter.

Best wishes;

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Latest Questions
Ramalingam

Ramalingam Kalirajan  |10872 Answers  |Ask -

Mutual Funds, Financial Planning Expert - Answered on Dec 06, 2025

Asked by Anonymous - Dec 06, 2025Hindi
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Dear Sir/Ma'am, I need some guidance and advice for continuing my mutual fund investments. I am a 36 year old male, married, no kids yet and no debts/liabilities as such. I have couple of savings in PPF, NPS, Emergency funds and long term investing in direct stocks. I recently started below mentioned SIPs for long term to grow wealth. Request you to review the same and let me know if I should continue with the SIPs or need to rationalize. Kindly also advice on how to invest a lumpsum amount of around 6lacs. invesco small cap 2000 motilal oswal midcap 2700 parag parikh flexicap 3000 HDFC flexicap 3100 ICICI prudential largecap 3100 HDFC large and midcap 3100 HDFC gold etf FOF 2000 ICICI Pru equity and debt fund 3000 HDFC balanced advantage fund 3000 nippon india silver etf FOF 2000
Ans: You already built a solid foundation. Many investors delay planning. But you started early at 36. That gives you a strong advantage. You have no liabilities. You have long term thinking. You also have diversified savings like PPF, NPS, Emergency funds and direct stocks. That shows clarity and discipline. This approach builds wealth with less stress over time.

You also started systematic investments in equity funds. That is a positive step. Your selection covers multiple categories like large cap, mid cap, small cap, flexi cap, hybrid and precious metals. So the intent is right. You are trying to create a broad portfolio. That gives balance.

» Your Portfolio Composition Understanding
Your current SIP list includes:

Small cap

Mid cap

Flexi cap

Large cap

Large and mid cap

Hybrid category

Gold and Silver FoF

Equity and Debt allocation fund

Dynamic hybrid fund

This shows you are trying to cover many segments. But too many categories can create overlap. When there is overlap, you get confusion during review. It also makes portfolio discipline difficult. You may think you are diversified. But the holdings inside may repeat. That reduces efficiency.

Your portfolio now looks like:

Equity dominant

Hybrid for stability

Metals for hedge

So the broad direction is fine. But simplifying helps in long-term habit building.

» Fund Category Duplication
You hold:

Two flexi cap funds

One large and mid cap fund

One pure large cap fund

One mid cap fund

One small cap fund

Flexi cap funds already invest across large, mid, small. Then large and mid also overlaps. So the large cap exposure gets repeated. That may not add extra benefit. But it increases monitoring complexity.

So I suggest rationalising. Keep one fund per category in core. Keep satellite space for only high conviction.

» Core and Satellite Strategy
A structured portfolio follows core and satellite method.

Core portfolio should be:

Simple

Long term

Stable

Satellite portfolio can be:

High growth

Concentrated

Based on your thinking level, you can structure like this:

Core funds:

One large cap

One flexi cap

One hybrid equity and debt fund

One balanced advantage type fund

Satellite funds:

One mid cap

One small cap

One metal allocation if needed

This division gives clarity. You can continue SIPs with review every year. No need to stop and restart often. That reduces behavioural mistakes.

» Your Current SIP List Review with Suggested Streamlining

You can consider continuing:

One flexi cap

One large cap

One mid cap

One small cap

One balanced advantage

One equity and debt hybrid

You may reconsider keeping both flexi caps and both gold silver funds. One of each category is enough. Because too many funds do not increase returns. It complicates tracking.

Precious metal funds should not be more than 5 to 7 percent in your portfolio. This is because metals are hedge assets. They do not create compounding like equity. They act as protection during cycles. So keep them small.

» How to Use the Rs 6 Lakh Lump Sum
You asked about lump sum investing. This is important. Lump sum should not go fully into equity at one time. Markets move in cycles. So use a staggered method. You can invest the lump sum through STP (Systematic Transfer Plan). You can keep the amount in a liquid fund and set STP toward your chosen growth funds over 6 to 12 months.

This reduces timing risk. It also creates discipline. So your Rs 6 lakh can be deployed gradually. You may use 50% towards core equity funds and 30% toward satellite growth category. The remaining 20% can go into hybrid category. This gives balance and comfort.

» Regular Funds Over Direct Funds
One important point many investors miss. Direct funds look cheaper. But they demand deep knowledge, discipline, and behaviour control. Most investors lose more through emotional selling and wrong timing than they save on expense ratio.

With regular funds through a Mutual Fund Distributor with Certified Financial Planner qualification, you get guidance, structure and correction. The advisory discipline protects you during market extremes. That is more valuable than a small saving in expense ratio.

A personalised planner also tracks portfolio drift, rebalancing need and category shifts. So regular fund investing gives long-term benefit and behaviour coaching.

» Actively Managed Funds over Index or ETF
Some investors choose index funds or ETF thinking they are simple and cheap. But they ignore drawbacks.

Index funds or ETF will not avoid weak companies in the index. They will invest whether the company grows or struggles. There is no fund manager decision making. So when markets are at peak, index funds continue aggressive exposure. In downturns also they fall fully. There is no cushion.

Actively managed funds work with research teams. They can avoid bad sectors. They can shift allocation based on market and economy. Over long term, this gives better alpha and stability. So continuing with actively managed funds creates better wealth compounding.

» SIP Continuation Strategy
Once the rationalisation is done, continue SIPs every month without interruption. Pause and restart behaviour damages compounding power. SIP works best when you go through all market cycles. You benefit more during corrections because cost averaging works.

So continue SIP amount. You can also review SIP increase every year based on income. Increasing SIP by 10 to 15 percent every year helps you reach large corpus faster.

» Asset Allocation Based Approach
One key point in wealth creation is having the right asset mix. Equity gives growth. Hybrid gives balance. Metals give hedge. Debt gives safety. Your asset allocation should stay aligned to your risk profile and time horizon.

Since you are young and have long term horizon, higher equity allocation is fine. But as time moves, rebalancing is important. Rebalancing protects gains and restores allocation.

So review your asset allocation every year or during major life events like child birth, home buying or retirement planning.

» Behaviour Management
Many portfolios fail not due to bad funds. They fail due to bad decisions. Selling during correction. Stopping SIP when market falls. Chasing past return performance. These mistakes reduce wealth.

Your discipline so far is good. Continue to stay patient during volatility. Equity rewards patience and time.

» Financial Goals Clarity
Since you have no children now, you can decide your long-term goals. Typical goals may include:

Retirement

Future child education

Dream lifestyle purchase

Health care reserves

When goals are clear, investment purpose becomes stronger. So you can map each fund category to goal horizon. Short-term goals should not use equity. Long-term goals should use equity with hybrid support.

» Role of Review and Monitoring
Review once in a year is enough. Frequent review can create anxiety. Annual review helps check:

Fund performance

Expense drift

Category relevance

Allocation balance

Then adjust only if needed. This progress helps you stay confident and aligned.

» Taxation Awareness
Equity mutual funds taxation rules are:

Short term (below one year holding) taxable at 20 percent

Long term (above one year holding) gains above Rs 1.25 lakh taxable at 12.5 percent

Debt mutual funds are taxed as per your income slab.

So always hold equity funds for long term. That reduces tax impact and gives better growth.

» SIP Increase Plan
You can create a simple plan to increase SIP over time. For example:

Increase SIP at every salary increment

Increase SIP during bonus time

Use rewards or extra income for investing

This habit accelerates wealth. So by the time you reach 45 to 50 years, your investments could reach a strong level.

» Insurance and Protection
Before investing large, ensure you have term insurance and health insurance. If not already done, it is important. Insurance protects wealth. Without insurance, even a small medical event can impact investment plan. So review this part also. Since you are married, cover both.

» Wealth Behaviour Mindset
You are already disciplined. Just keep these simple principles:

Invest without stopping

Review once a year

Avoid funds overlap

Follow asset allocation

Avoid reacting to media noise

This helps you reach long term milestones.

» Finally
You are on the right track. Only fine tuning and simplification is needed. Your discipline is visible. Your portfolio will grow well with structure, patience and periodic review. Use the Rs 6 lakh with STP approach. And continue SIP with rationalised categories.

With time and consistency, wealth creation becomes effortless and peaceful. You just need to stay committed and avoid overthinking during market movements.

Best Regards,
K. Ramalingam, MBA, CFP,

Chief Financial Planner,

www.holisticinvestment.in

https://www.youtube.com/@HolisticInvestment

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Dr Dipankar

Dr Dipankar Dutta  |1837 Answers  |Ask -

Tech Careers and Skill Development Expert - Answered on Dec 05, 2025

Career
Dear Sir, I did my BTech from a normal engineering college not very famous. The teaching was not great and hence i did not study well. I tried my best to learn coding including all the technologies like html,css,javascript,react js,dba,php because i wanted to be a web developer But nothing seem to enter my head except html and css. I don't understand a language which has more complexities. Is it because of my lack of experience or not devoting enough time. I am not sure. I did many courses online and tried to do diplomas also abroad which i passed somehow. I recently joined android development course because i like apps but the teaching was so fast that i could not memorize anything. There was no time to even take notes down. During the course i did assignments and understood the code because i have to pass but after the course is over i tend to forget everything. I attempted a lot of interviews. Some of them i even got but could not perform well so they let me go. Now due to the AI booming and job markets in a bad shape i am re-thinking whether to keep studying or whether its just time waste. Since 3 years i am doing labour type of jobs which does not yield anything to me for survival and to pay my expenses. I have the quest to learn everything but as soon as i sit in front of the computer i listen to music or read something else. What should i do to stay more focused? What should i do to make myself believe confident. Is there still scope of IT in todays world? Kindly advise.
Ans: Your story does not show failure.
It shows persistence, effort, and desire to improve.

Most people give up.
You didn’t.
That means you will succeed — but with the right method, not the old one.

...Read more

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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