Disputes in Mediclaim
There is a dispute when your MEDICLAIM claim is (1) denied totally (2) denied in part or (3) cashless service is denied but reimbursement is allowed.Understand your policy before you move on to the “ grievance redressal mechanism “ .
Please read about “Understand Your Policy” before moving on to disputes.
Please read about commonly missed documents in reimbursement claim…
Total Denial of Claim
This happens if the Insurance company feels that your claim falls into the “ exclusion” or “waiting period”. Some claims are denied because the original documents required by the company are not supplied or some of them are found to be fake or fraud. The status of the claim can be checked from the portal of the Insurance TPA. The commonest cause of total denial is that claim falls into one of the pre exisiting disease clause. You could have exhausted your claim limit with other claims earlier in the policy period. You may also be using the wrong policy eg critical care policy or a top up policy .
Read about the “Exclusion clause”
Read about the “Pre exisiting Disease Clause”
Read about the “ Waiting Periods”
Partial denial of Claim
This is a very common cause of dispute when the company pays an arbitrary sum much less than the claimed amount. The company usually cites the clause that they have paid the “reasonable and customary cost of treatment”. However, many Ombudsmen ruling strike down this clause . Another common reason of part payment is that the higher category room was taken and the insurance company used the clause of “ sublimits” to reduce the amount. This again has been set aside by many a Ombudsmen or Consumer Court Ruling.
Cashless service is not allowed
It is not uncommon to find Mediclaim claims where cashless service is denied. The commonest cause of denial of cashless service is that the admission is in a “non PPN GIPSA”. The four PSU Insurance Companies ( New India Assurance, National Insurance, Oriental Insurance, United India Insurance ) together called “General Insurance Public Sector Association or GIPSA, have formed a “Preferred Provider Network” which is a very ambiguous network and which has been disallowed by many a Ombudsman and Consumer Court Rulings. Cashless service is usually denied from non PPN hospitals for PSU companies. Even in PPN hospitals only a part of the hospital expense beyond cashless service is paid.
Read up about “Cashless service only in PPN Hospitals.”
How to proceed with your Mediclaim Disputes
The first complaint about Mediclaim disputes have to be made with the Insurance Branch Office. The address of the branch office is available in your policy document.
see the sample complaint letter to Branch Office
You may next escalate your grievance to the Regional Office but Unfortunately in most grievance the Insurance Companies sit tight and do nothing about it. This has been bitterly reorded by the Executive Committee of Insurance in their annual report of 2016-17. The next complaint destination is to the to the Consumer Affairs cell of IRDA which nudges the Insurance Company at times to take up the dispute earnestly. Next is the Insurance Ombudsman and finally the Consumer Courts.
The Ombudsman
When the Insurance Office is silent on your complaint, which is very often the case, a complaint to the Insurance Ombudsman is the next step. The address of your Insurance Ombudsman would be mentioned in the policy. The Insured or the nominee or the assignee can lodge a complaint and you are not allowed to take along a lawyer. No adjournments are allowed. If is a very effective forum for complaints and will take between 6 months to an year. An ombudsman cannot , however, awrd compensation which the consumer court can.
Read on to know about the Insurance Ombudsman
Download the Ombudsman Complaint Form
Before proceeding to the Ombudsman with your Complaint, you must write to your Insurance Branch office and then give one month time for them to reply. You can complain to the Ombudsman only if your branch does not reply to you or does not give you a favorable reply.
The Consumer Court
The District Consumer Court which is called the Consumer Redressal Forum is the next step. You can move a complaint without an advocate but it is advisable to take one. In case your demand of compensation exceeds Rs 20 lakhs then the complaint has to be lodged with the State Consumer Disputes Redressal Commission . They will admit complaints up to Rs One crore. Beyond Rupees one crore, the National Commission has to be approached. However, most Mediclaim Disputes are settled in District Forum and one needs to go to the State Commission only for appeal. A Consumer District court case can take anything between one to two years to be over and a State Commission appeal might take one year.
Read on to know about the Consumer Court
INSURE YOURSELF ADEQUATELY, KNOW YOUR POLICY, SUBMIT YOUR CLAIM FORM WITH ALL DOCUMENTS AND HOPE THAT THERE WILL NOT BE DISPUTE