Why TPAs resist in reimbursing genuine expenditure incurred on ayurvedic treatment {all conditions fulfilled including admission in ayurvedic hospital}. All proofs submitted.

Ans: Hi Chiraag, hope reading my answers cleared your doubts. To answer your personal query, the insurance company must have mentioned in your policy document that to raise a claim under your policy, you will need to be admitted for minimum 24 hours and without that the claim will not stand.

Also, the treatment in this case needs to be done in an AYUSH recognised hospital to avoid failure of claims.

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.

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/.

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