First Grievance Letter to your Branch
Your first grievance letter should be to your Insurance branch office even though your TPA will be dealing with your claim. Please include as much details about your policy and claim as possible . such as policy number, in case of group Mediclaim Policy – the name of the Group, the number of the TPA ID Card, the Claim number, date of hospitalisation .
You should be clear about why you are complaining and mention it clearly. In this sample letter the Insurance Company had unfairly deducted some money saying it had to be paid by cheque. The Insured had made the payment by credit card and therefore took up the matter as a grievance.
Only when you do not receive any reply from the branch within one month ( written reply – not telephonic ! ) can you go to the next level. The first letter has to be complete with all details and clearly state what you want.
It makes your letter strong if you cite some policy clause in support of your claim. You can also find some clause in IRDA Health Insurance Regulation in support of your claim. You may include them in your letter.
Read up about Insurance Regulations
Read up the details of your reimbursement claim
Here is a true letter with all details and names changed to protect privacy
Rita Singh
House no 4, 1st Road Lado Sarai
New Delhi 110030
24th July 2018
Freedom India Insurance Company
South West Delhi Branch
Lado Sarai New Delhi 110030
Sub: Grievance on partial repudation of Freedom India Health Insurance Claim
Ref: Policy no 7902000/34/18/95/0000006:Bank Name CCHD Bank Ltd Saket Branch:Claim No 17024717 :TPA Myhealth Insurance TPA Pvt Ltd:Insurer Claim No TP00420200018900000424
Name : Rita Singh TPAID 6232187688
Dear Sir,
While settling my claim for hernia surgery referred to as above your Myhealth Insurance TPA Pvt Ltd has unfairly disallowed Rs 4400 from the payment of Rs 14400 for surgeons fees out of a total payment of Rs 22200 which was made against printed numbered receipt no 33025 dated 12/6/2018 of Jivan Sathi Hospital by card payment through SBI TID 33608915 card no XXX9979 authorisation code 890211 batch 120 of 12-Jun-2018. While allowing only Rs 10000 the TPA has cited clause 3.38 of my policy which states
“However, the bills raised by Surgeon, Anaesthetist directly and
not included in the Hospital Bill shall be paid provided a numbered Bill is produced in
support thereof, for an amount not exceeding Rs. Ten thousand, where such payment is
made in cash and for an amount not exceeding Rs. Twenty thousand, where such
payment is made by cheque.”
By this reasoning your TPA Myhealth has equated “digital payment through card” as “cash” payment while interpreting the policy clause and has penalised the Insured for making digital payment in gross violation of the Directive of the Finance Ministry of the Government of India of encouraging Digital payment.
Further more, by allowing your Myhealth Insurance TPA Pvt Ltd to decide claim you have violated the IRDAI Health Insurance Regulations 2016 clause 33 c, which clearly states :
c. Insurers shall ensure that the TPAs are not carrying out the following activities as part of the agreement
i. Claim rejections/repudiations with respect to the health insurance policies;
ii. Payments to the policyholders, claimants or the network providers;
I request you to make immediate payment of my outstanding claim amount and correct your gross violation of IRDAI Health Insurance Regulations 2016 failing which I shall be at liberty to approach appropriate Fora for grievance redressal in this matter.
I shall be looking forward to hearing from you.
Yours faithfully,
Rita Singh