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“Health insurance claim filing within 7 days is often unfeasible”

A leading Mumbai-based surgeon (who prefers to be anonymous) tells the inside story about mediclaim lacuna based on real life experience. Excerpts of the interview:

Moneylife (ML): Can you share real life health insurance issues that you have come across?

A. Many insurers now insist on filing the claim in seven days. Suppose a patient gets discharged from a high-end hospital in Mumbai, the customer needs to make an application to get a copy of indoor papers. Big accredited hospitals have stringent guidelines and hence take almost two to three days to get the papers organized before they can give a copy to the patient. Imagine a senior citizen who has been discharged and his equally old wife looking after him (common scenario with kids living abroad). It is difficult for them to make rounds of hospital to get the papers. Insurance companies will ask them to produce a letter to justify the delay. Even after accepting the letter, new set of queries may be raised. You are lucky if you receive the claim payment after six months.

I personally operated my own family member for which I do not receive any doctor's fees. The claim was for other charges for implants, consumables, etc. We have an insurance scheme run by our doctors' association where the claims get settled easily because we have a clause in which the committee doctor's word is final. All the papers were organized and sent as per schedule. It took me five months to get the money back. I did not have to fight because our association personnel do it for me, but the insurance company delayed the process for three months saying the claim was filed after seven days.

There was Rs4,000 deduction for reasons like use of a thermometer, dressing material, etc. I could have easily got that money if I had fought; it was just wrong to cut money for using a thermometer. I did not think it was worthwhile to spend time on this small amount, but this is a trick wherein if you cut small amount after delaying the payment and the claimant is not in a mood to fight.

ML: Third party administrators (TPAs) have been accused of many health insurance problems. What is your take?  

A. The TPA system has spoilt everything. A TPA appoints BAMS/LCEH qualified doctors to verify the documents. Interestingly if a homeopath writes an allopathic drug he can get punished according the Supreme Court ruling for "cross pathy" practice but the same person can dictate terms to a qualified surgeon like me and question my treatment plan?
The corruption levels in TPA are phenomenal. You pay an X amount and all your bills get cleared, you do not and they will harass you no end. I will give a real example. I had a patient who needed surgery as per a MRI. The surgery was planned, but he disappeared for a few days and then came back saying he wants to do another MRI. I asked him the reason. He said he got himself insured now and wanted to claim the surgical cost; the old MRI would be a hindrance.

I told him that insurance company will not pay the claim. He said that he will bear the cost if the claim is rejected. We went ahead and got another MRI (within six weeks of the first). I told him that even if he would get a cashless approval it will be for only X amount and the rest he would have to pay. He had the same answer "Doctor, just put your total cost and I will manage the rest".

We went ahead and did his surgery. We got an approval from the TPA in six hours for an amount which was Rs50,000 more than the amount they would have sanctioned for the same surgery in the same hospital for another insured person. I was shocked. I finally asked him how he had managed all this. He simply said "Doctor, I have a car rental business and I insure all my cars with this company, so they just cannot refuse to entertain me". He had no cover when he got injured, but easily got cashless approval from the TPA for an amount higher than the procedure cost.

ML: What are some other issues with health insurance that insurers should focus on?  

A. I performed one surgery with new technology instead of longer version which would have needed hospitalisation. The patient was fine after the surgery and hence went home in eight hours. She then realized that she had a mediclaim and submitted her papers for a claim. She was refused a claim saying that she did not stay for 24 hours. I wrote to the TPA on her behalf and explained that the procedure did not require a stay and I was actually saving the insurance company a lot of money by doing a surgery like this. It fell on deaf ears. The patient's husband was resourceful and got after the TPA. He got the claim of Rs18,000 settled after eight months of fight.

Insurance companies cover cataract procedure; it shows that they are selective of which day-care procedures they want to cover. The bill for a day-care is much less than for admissions for over 24 hours. I have repeatedly asked the CEOs of insurance companies as to why they disallow day-care surgery when it is actually cheaper for them. They keep saying we are updating the schedules, but in reality nothing like that happens. Both the patient and the treating doctor are harassed to no end, which makes the patients feel that they should cheat; I fully agree with them.

ML: What can customers do take care of health expenses apart from mediclaim?
A. I would advise people to park some money in a mutual fund and build up a fund for medical emergencies. I agree that it would take time but once a corpus of say Rs5 lakh builds up, it would be a good tool to use against the medical illnesses.

Read first part of the interview here:



Aleck Fernandes

5 years ago

Doctor, It is an expected fact that to sudmit claim within 7 days of discharege is not atall feasible. Only United India Insurance co. Ltd. is out to harass the insured person by putting this clause in the Med-Claim Policy. No consideration is given to aged insured person also. If the claim is to be submitted within 7 days, no ruling is applicable for settling the claim after 4-9 months. Cataract claim is also settked after 3 months that too after many follow up. If New India has come down from earlier 60 days to 30 days why not United India Ins. co. Ltd. IRDA seems to have no control to bring in regulation to correct act by insurance Co and to stop harassament.You have learnt a lesson by your mistakes. You thought you did a big favour to the Insurance Co. and expected a favour in return? You should have submitted your professional charge receipt with the claim. Even if T.P.A. made any deduction by way of Reasonability clause - which is unreasonable, your family would have tend to gain and would be very comfortable having deducted Rs. 4000/- . You learnt further with experience of another patient in Car Rental business how he managed to get the claim settled with ease and how fast. Many things happen in processing Mediclaim by T.P.A. and the Insurance Co. IRDA boast of Insurance co. have check on fraudulent claims. Two Nursing Home on PPN list have submitted fraudulent claims which came to THE Notice of New India Assurance. PPN has appointed such caliber of Nursing Home only wanting to business on their approved list of hospitals to give cashless service. Eye wash to insured person showing appointment of 95% Nursing Home and 5% Good named Hospital who turn down the insured person to give cashless service as their relation with the T.P.A. is painful.To many getting cashless benifit on the policy is more a pain then comfort.


5 years ago

I got my Dermoid Cyst On Occipital Region ( left side back portion of head/skull ) done at a very small hospital (about 30 beds - 5 floors) at Andheri(east) Mumbai after due confirmation from TPA.(diagnosis written in detail by surgeon including DAY CARE SURGERY was sent well in advance to TPA as an intimation for a claim and acknowledged by TPA in writing ).

Selection of small hospital was made due to less expense and proximity from my home for follow-up treatment.

Sum Insured was Rs.1,50,000/-(Rs.One Lac Fifty Thousand ) .But my claim of Rs.10,000/-(Rs.Ten thousand) was rejected by New India and MD India (TPA) since I DID NOT STAY AT HOSPITAL FOR OVER 24 HOURS.

Surgery was done by a surgeon ( MD-MS)with local anesthesia and it took over one hour with about 10 to 12 stitches and cyst size of Table tennis a ball was removed.

Photograph of syst is still with me.

TPA and New India Assurance -maintains after going through all papers and post surgery pathology reports-that such surgery CAN BE DONE BY A GENERAL PRACTITIONER (GP) AT A DISPENSARY ??????

Does a GP have a sterilised dispensary and other related equipments for performing such operation ?

Will Chairman/Senior Managers of New India Assurance , MD India , IRDA and Insurance Ombudsman - go to a GENERAL PRACTITIONER (GP) for such surgery ?????

COMPLAIN TO IRDA gave no result. IRDA is favouring New India and TPA MD India. It appears to me that IRDA is another bureaucratic organisation-full with red tape and lethargic attitude toward a policy holder and favour Govt. owned insurance cos.

( I presume IRDA and Ombudsman officials are EX General Insurance employees )

My appeal is pending with Insurance Ombudsman at Santacruz (West),Mumbai for over TWO months. ( I do not expect any miracle from Insurance Ombudsman office ).

Insurance Ombudsman office of Santacruz ,Mumbai still functions in pre Independence British era of SLAVERY.

About two years back , a friend of mine - an insurance agent - wanted to participate in a hearing case of his client ( mediclaim policy holder ) for rejection of a hospitalisation claim at Insurance ombudsman office,santacruz (west,mumbai .

Policy holder was from interior village of Maharashtra and he was not conversant with English and even fluent Hindi. Agent requested Ombudsman to participate in hearing.HOWEVER INSURANCE AGENT WAS NOT ALLOWED TO PARTICIPATE IN HEARING OF CASE IN SPITE OF REQUEST MADE BY INSURANCE AGENT TO OMBUDSMAN REGARDING POLICY HOLDER -NOT ABLE TO UNDERSTAND ENGLISH AND HINDI LANGUAGE.

Insurance agent was told that he is NOT allowed to remain present in such hearing.ITS RULE FROM GOVT./OMBUDSMAN HEAD QUARTERS.!!!!!!!!!!


Had I done my surgery at a 5-star hospital with a bill of @ Rs.1,00,000/- insurance co.might have paid my claim !!!!!!!!




In Reply to deepaksb 5 years ago

YOU ARE RIGHT IN WRITING THAT -------- Will Chairman/Senior Managers of New India Assurance , MD India , IRDA and Insurance Ombudsman - go to a GENERAL PRACTITIONER (GP) for such surgery ?????



M K Gupta

5 years ago

For lesser humans, getting Insc clalims itself is an impossibility. Another aspect is not usually discussed in this regard. The bills are prepared only after the patient is "discharged"from the hospital's care. But, until the Insc. co.'s man comes or clears okays the bill, the patient is not "released"from the custody of the hospital which charges for the extra time too!

Koduri Srihari Rao

5 years ago

Appreciate the suggestion given by the doctor for alternative to mediclaim. If we start maintaining our own fund in the form of Bank RD/Mutual Fund SIP or on normal endowment type policy in Life insurance and earmark it for medical emergencies, we can get rid of all the harasments from Medical insurance companies, infact we also can make a lot of savings. But one should be have a good financial discipline to manage the fund. I am following the same technique.


Arun M Purohit

In Reply to Koduri Srihari Rao 5 years ago



Railways not responsible for luggage lost in passenger custody?

If any luggage is not handed over to railway administration against a proper receipt, the Railways will not be responsible for any theft or loss of the luggage, says the State Consumer Redressal Commission


Mumbai: The Maharashtra Consumer Redressal Commission has observed that if any luggage is not handed over to railway administration against a proper receipt, the Railways will not be responsible for any theft or loss of the luggage, reports PTI.

The commission was hearing an appeal filed by a Divisional Railway Manager (DRM) of Central Railway against the order of the district consumer redressel forum which had directed the DRM to pay Rs1.35 lakhs to US resident Anagha Prasanna Walimbe for loss of her gold ornaments.

"It is not stated anywhere that the suitcase containing ornaments was under lock and key and when it was opened after leaving Pune railway station and reaching residence," the bench presided by commission member SR Khanzode observed recently.

Khanzode also observed that the complaint of theft lodged with the Railway Police was closed and made final as ornaments were not traceable.

In the absence of any cognate evidence placed on record by Walimbe, the railway administration shall not be held responsible for negligence or rendering deficient service to provide security/ protection to the luggage in the custody of the passenger, though travelling on a reserved ticket.

The Solapur district consumer forum had directed the railways to pay Rs1.35 lakhs along with 9% interest after Walimbe filed a complaint saying that she travelled in the reserved second class on 25 December 1998 from Solapur to Pune.

In her complaint, she said her luggage was kept under lock and key with her and after reaching Pune railway station, she took an autorickshaw to reach home. When she verified her luggage at night she found that her gold ornaments were missing from the suitcase.

She filed a case with the Railway police the next day.

Walimbe had alleged deficiency in service on the part of the railway administration and said there was no police bandobast or ticket collector to take care of her belongings of the passengers.

However, railways said she did not deposit her luggage with the administration. Accordingly, she did not take a receipt.


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