New India Assurance pays Rs34,313 for mediclaim initially rejected: Another Moneylife success
New India Assurance has paid Rs34,313 towards a mediclaim that was earlier rejected by the TPA on flimsy grounds. The insured senior citizen has been a customer for 20 years, but that did not help to get the claim paid. Moneylife Foundation’s intervention helped
 
Sujit Banerjee (name changed), a retired senior citizen of 73 years, had approached the Moneylife Insurance Helpline of Moneylife Foundation seeking help with his rejected mediclaim on flimsy grounds by the TPA (third party administrator). The TPA alleged that the insured suffered from hypertension for 15 years without having any documentary support. The TPA even chose to ignore medical certificate of the illness from a doctor with super speciality degree in neurology. Inadequate medical expertise of the TPA staff has been reported by the media for a long time.
 
Taking the complaint to the grievance cell was the next step followed by the Moneylife Insurance Helpline in escalating the matter to the GM, grievance cell of New India Assurance. The claim was paid for Rs34,313, overturning the TPA’s debatable decision.
 
The case proves that TPAs should not be settling claims, which is included in the new health insurance guidelines from IRDA (Insurance Regulatory and Development Authority). Insurance companies have much more expertise on medical intricacies than a TPA. The regulations put the onus on the insurer to give specific grounds of settlement and denial of claim. In short, the insurance company cannot play the blame game that the TPA is making decisions on the claims.
 
MD India (TPA) had repudiated Mr Banerjee’s for a claim related to illness of reversible ischemia with neurological deficit, arguing that the “Current illness is a complication of hypertension which is since 15 years as per indoor case papers’’. According to Mr Banerjee, “I do not know from where the TPA got this information as neither the case papers nor the discharge card made any reference of 15 years history of hypertension. Somewhere a mention is made of mild hypertension which is natural as an age-related problem.  I am a customer of New India Assurance for the last 20 years or so.”
 
On receipt of the TPA repudiation letter, Mr Banerjee contacted Dr Neeta A Mehta, under whom he took treatment at Nanavati Hospital in Mumbai. She readily issued a certificate mentioned that the illness was “more like Transient Ischemic Attack” and further added that “mild fluctuation of blood pressure is not the cause of this attack’”. Mr Banerjee says, “Dr Neeta Mehta is an eminent neurologist of repute and besides being an MD also holds a super speciality degree of DM in Neurology. I wonder how the TPA can ignore the opinion coming from such an eminent doctor.” Moneylife’s contribution helped to get justice for Mr Banerjee.
 
Interestingly, at a January 2013 high court hearing of a public interest litigation (PIL) filed by Gaurang Damani, IRDA member (non-life) M Ramaprasad admitted that even veterinarians are appointed by the TPAs in addition to ayurvedics and homeopaths to assess claims. There have been cases where specialist doctors were not able to convince the need of specific procedure to TPA doctors, who may be well qualified in their respective field but not in the specialised allopathic stream.
 
Mr Banerjee also pointed out that all New India Assurance mediclaim policies showed no pre-existing diseases except for the policies for the years 2009-10 and 2010-11 which erroneously showed ‘’pre-existing hypertension and diabetes’’. Mr Banerjee thinks that it may be due to a clerical error inadvertently inserted and the loading was recovered. He had to protest for such a fallacy and the pre-existing illnesses were removed in the subsequent policies till today. It affirms what Moneylife suggests about the importance of checking your policy document so that there is no discrepancy in the product renewed or sold to you.

 In case you have an insurance issue, please write to Moneylife Foundation. Click here
Comments
vibin wilson
5 years ago
In my case Raksha TPA deducted Rs. 10000 arbitrarily.. New India is the insurer.. They r not playing nebulozation charges which is payable according to my group mediclaim policy conditions.. Can u plz help money life.. I have emailed u all the details of my case.. Plz help..
ABHA CHAWLA MOHANTY
9 years ago
THE PUBLIC SECTOR INSURANCE COMPANIES ARE NOT SERIOUS ABOUT CUSTOMER CARE, AND ,POLICY PERCEPTIONS THEREIN FOR DOING GOOD....,NEED ,STRINGENT CHECKS FOR CALLOUS WORKING...!
revribhav
9 years ago
The General Insurance sector of india is virtually without any regulator.
(a) The IRDA: It's grievance redressal is without any teeth.It has told the Central Information Commission that it is not an authority over a particular insurance company.
A particular divisional manager of an insurance company who got me dismissed from insurance company has made himself millionaire on account of suspicious mediclaims.
(b) GIPSA: It is not registered with any statutory authority,you cannot legally sue GIPSA,though it is virtually an authority over 4 general insurance companies and GIC
(c) Ministry of Finance Insurance Division:It has told me in writing that it is not a complaint redressal authority over insurance company,though as per the General Insurance Act,it exercises administration over the insurance companies.
ABHA CHAWLA MOHANTY
Replied to revribhav comment 9 years ago
THE INSURANCE SECTOR ESPECIALLY PSU NEEDS A VERY UPRIGHT VIGILANCE AND ,AUDIT TEAMS WITH CAG MONITORING....?
SATISH BHATIA
9 years ago
Dear Money life Team, Thank you very much for sharing the experience of Mr. Banarji. I has really given so many points to re-check with policy, which will definitely be an eye opener for us.
It has marked a big question on TPA's and their services. As now days many cos are working without TPA.. can be a better solutions for customers.
Thanks n Regards,

Satish Bhatia
Advisor
Max Bupa
revribhav
9 years ago
While filing right to information I discovered a horrible fact about the said insurance company.
The well known bribe taker obiviously protected at the highest level showered with public money who was caught red handed demanding gratification during January 2003 near Jaipur regional office by a reputed law enforcement agency against corruption enjoys an altered name.
His present name is altered,that is,not the name with which he entered the services of insurance company.
ABHA CHAWLA MOHANTY
Replied to revribhav comment 9 years ago
DUTY OF DISCLOSURE STILL APPLIES...MAY THE NAME SURFACE FOR GOOD,,,,
revribhav
9 years ago
The said insurance company dismissed me on a so called grave allegation of leaving headquarters,the company chairman was seen in the company of a well known bribe taker who still receives public money of about 50K salary under salary roll no. 26019.Evidence may be seen at the following URL:
https://twitter.com/revribhav
Arun M Purohit
9 years ago
MANY THANKS TO MONEYLIFE FOR SUCH A HELP TO NEEDY SR.CITIZENS , CONGRATS , MONEYLIFE ALSO NEEDS TO TAKE UP THE MATTER REGARDING AGENTS / EMPLOYEES WHOSE DOESN'T HAVE IRDA LICENSE RECRUITED MOSTLY BY PVT. INSURERS , THEY ARE JUST A 10th / 12th PASS / GRADUATE ONLY. AS PER MY OBSERVATIONS AND LOOSING MINE BUSINESS TOO BY MY RELATIVES. I PERSONALLY POINTED OUT TO PVT. INSURERS , THEY CONVIENNCED ME THAT FOR HEALTH INSURANCE SELLING , LICENCE NOT REQUIRED. TILL DATE I LOST A PREMIUM OF Rs.50,000/- , MY COUSIN SELLING A RELIGARE HEALTH INSURANCE POLICIES AND TARGETTING MY CLIENTS ,HIS RM FROM RELIGARE ALSO DOESN'T HAVE IRDA LICENSE. THEY ARE MISSELLING A PRODUCT WITHOUT DISCLOSING IT'S NORMS. I AM EXPECTING A PROMPT ACTIONS FOR THE BENEFITS OF ENTIRE INDUSTRIES.

ARUN PUROHIT - IRDA QUALIFIED / AGENT OF THE ORIENTAL INSURANCE M : 09377702264 ,
Venkatesh
9 years ago
They shd also be fined for a few crores as penalty for rejecting a genuine claim. This will only make them more accountable. With this case what has been achieved? THe insurance company number crunchers will tell the TPA to reject over 75% of the claims, of which only 50% will fight back of which they can still reject 25% and end up with 50% claim rejection thereby lining their pockets. What I would also like to know is, does IRDA monitor these claim rejection percentages and is there transparent data on this available anywhere companywise ???
raj
9 years ago
Thanks for all the comments!
vinay kashelkar
9 years ago
As per my knowledge (if New India's terms and conditions are not different) any disease pre-existing at the time of proposal is not covered for first 4 years if continuous renewals without break are done. But from the 5th year all pre-existing diseases are automatically covered. There is no question of denying any claim for pre-existing diseases/tendencies.
vns
9 years ago
Retired people belonging to PSUs and having Mediclaim Insurance must thank Moneylife which stands to help those who are sr. citizens and really needy for such a help.Alternative is that Mediclaim Insurance companies combined with the TPAs will fleece the poor chaps.
vivek sharma
9 years ago
Great work Raj! Moneylife team believes in helping needy which is indeed great.
Anil Paranje
9 years ago
Great work MoneyLife! God bless!
N Kanitkar
9 years ago
Well done Moneylife. Hearty congratulations. Shoddy job from New India Assurance. Thanks to your earlier article on Mediclaim, chose the same from OBC at half the premium.
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