Urban Problem Solving- Full Settlement of a MEDICLAIM, a Real Challenge

Preface

Continuing from my introductory blog-post, this is the first installment of my personal experience in solving essential personal problems faced by us in Kolkata.This deals with a very commonly known subject about which most of the salaried people, retired people, even affluent people are quiet well aware. This is known as Mediclaim Insurance.

With the increase in the number of common & difficult diseases faced by all sections of the society in our regular life and the cost of medical treatment going up sky high it is becoming very difficult for the common people to bear these out of budget expenses from their limited income.  In view of these, Medical Insurance emerged as some sort of relief for all state of people in the society way back in 1986.By 2010, more than 25% of India’s population had access to some form of health insurance (Source: Wikipedia). However this concept has not been still widely accepted by a larger section of the society. There is a reason for it, which you will understand from my personal experience regarding Mediclaim Insurance.

Mediclaim Insurance – My first hand experience 

As mentioned in earlier blog-post, presently I am 76 years old. I started my Medical Health Insurance (Mediclaim) just on the eve of my retirement from service on December 1995 with one of the above mentioned four Public Sector Undertaking Insurance Company for self & my wife. I am renewing the same since then till now religiously before the due date.

In Kolkata one of my respected Senior Dada acted very efficiently as an agent of the Insurance Company and was maintaining everything efficiently. However due to old age he handed over the assignment to his known agent.  This agent was doing his job as a routine affair. He deposited my premium in time. He also deposited the claim form with all the documents to respective Third Party Administrator’s (TPA) Office as and when required. However he avoided any responsibility for any dispute arising from claim settlement. It is to be noted that since the age limit of both mine & my wife exceeded 70 years I have to pay a hefty sum of more than Rs 16000.00 annually covering the Medical Insurance of us for a paltry insured sum of Rs 125000.00 each. 

During my long duration of Mediclaim, I only applied for claim three times for the cataract surgery of my wife as well as of mine. The claim was made on 2009 for my wife and in 2010 and 2014 for me.  For the claim made on 2009 & 2010 TPA was a company situated in Kolkata, while from 2011 TPA was changed to a Pune based company which had a regional office at Kolkata. 

On the previous two occasions the claim forms were submitted to the parent Insurance Company, who used to forward the same to respective TPA for claim settlement. In these two cases the claims were settled in full without serious problems. But with the change of TPA, we were directed to deposit the laim forms to the newly selected TPA & the problem started immediately.

This problem of claim settlement started with my last cataract surgery operation in February,2014. The operation was carried out in the same Eye care Nursing home near Park Circus like previous two operations. This nursing home is not enlisted in the Hospital and Nursing Home as per TPA's list. Hence i opted for direct reimbursement to my designated Bank account at the end of operation. Previous two cataract surgeries were performed also with the same payment option. 

My operation was carried out on 11th February, 2014. i deposited the claim form along with all the original documents mentioned in the claim form to the Regional office of my TPA through my agent on 18th February, 2014. While submitting the claim form along with all the documents, I attached a detailed list of the same as various annexure.  I kept copies of all documents & annexures & the receipt of the claim form & documents from the Regional office as evidences for future use.

My claim money arrives, but ….

My previous two claims were settled after one month of my submission of claim. However this time i got a message in my mobile as early as on 24th February about the settlement of my claim. Initially I was happy that the claim has been settled so early. However, my joy was short lived.

I discovered that the newly selected TPA has approved an amount of Rs 20,283.00 against my total claim of Rs 23,203.00, thereby deducting Rs 2920.00 without any explanation. They also promptly deposited the sanctioned amount to my designated Bank account on 26th February itself. Fine, that was a prompt service. But what happened to the amount of Rs 2920.00? Why that was deducted?

I strongly objected to this unilateral decision of TPA & sent a strong letter on 25th February itself after receiving the message. I received their reply giving details of deductions on four counts on 28th February, 2014. After going through the same, I found the reasons for deductions as fully unjustified on flimsy grounds & not as per my policy documents.

The deductions on two counts amounting to Rs 1450.00 were due to non-payment of operational charges for two essential surgical instruments essentially required for the cataract surgery. The reasons shown for their deduction were that they considered their inclusion in the Operation theater charges, and thus were not ready to pay the operational charges for these instruments.

This clearly exposed TPA's lack of simple general knowledge as well as technical knowledge about the Cataract surgery operation.  After studying my policy documents & discussion with my Doctor in the nursing home, I strongly sent two letters to TPA on 28th February and 3rd March, contesting all their deductions as unjustified, flimsy and not as per the policy documents. 

Technical terms explained to get some sanction

In my letter, I explained them the meaning of the term "operation theater" & their non relevance to use of surgical instruments. I also pointed out the relevant clause of the policy mentioning eligibility of separate payment admissible on these two counts.

They seemed to understand. Almost immediately, I received a message on 4th March itself informing a further sanction of Rs 1450.00 out of Rs 2920.00 deducted earlier. They sent me the details of this approved amount mentioning the sanction of this money on two counts which were earlier disapproved by them on 5th March. The customer care group was found to be a pack of confused lot. The members were contradicting each other all the times on the same subject.

TPA fighting for residual amount

However they still insisted disapproval of balance Rs 1470.00 on two counts. These were for Rs 1270.00 for the lens charges as deemed excess from their approved rates and believe it or not a paltry sum of Rs 200.00 for a receipt given by family physician in his own letter pad terming as non authentic. 

I contested the same and sent a strong rejoinder to TPA mentioning that their claim was unjustified citing specific clauses of policy document. I explained that the term 'authentic' is a relative term & the policy document mentions only original receipts which I did religiously. What more ‘authentic’ proof I can give other the Doctor’s receipt of fees in his original letter pad and in his handwriting? Further there is no higher limit in the lens charges as per policy document. Hence their unilateral decision is unacceptable. 

In spite of my repeated explanations to TPA's customer care department, they were neither agreeing on further payment nor properly answering to the arguments mentioned in my letters. It seemed as if they were headstrong as to keep some residual amount with the attitude “Why to give all he claimed?”

My agent put up his hands as he always did. He said that the Rs 200 can be managed, if I can ask my Doctor to give a receipt in his receipt book instead of the letter Pad. Receipt book indeed! I did not pay heed to his absurd proposal and started to plan for my second strategy.

Strategy to get the balance claim money back

Many may have left the battle at this point as Rs 1470 has literally not much value today. But for me, it was a matter of principle. Besides I am paying them Rs 16000 as premium per year. If it was Rs 1, I would have fought for it too.

I wrote a letter by email on 7th March, 2014 to the Senior Executive of my Parent insurance company against TPA's unjustified deductions explaining all the facts right from the beginning. I also enclosed scanned copies of all the relevant documents. But there was no reply. The days passed on, one week passed on, but there was no reply.

After an interval of ten days, I gave a ring to this senior executive to know if any action has been taken against my complaint. Due to his busy schedule, the executive officer first could not recollect the contents of my letter. However on detailed explanation he remembered the case and assured me of proper actions after examining all the documents from TPA on this issue. 

Then started my trial of patience for pursuing the matter with the Insurance Company's executive by ringing him up after every 10 days and asking for the actions from his side. Knowing very well my age, he behaved irritatingly with me at times. However, in spite of his irritating behavior, I did not give up chasing the matter with him. Sometimes he did not pick up the phone, sometimes he was too busy.

My dogged pursuing pays off

Finally after pursuing the matter for one and half months, the Senior Executive officer of the Insurance company relented & gave a befitting  letter to the MD of TPA on 17th April  negating all their reasons for deductions from my legitimate claim point wise. He asked them to pay the balance sum of claim of Rs 1470.00 at the earliest. 

In this situation, the TPA had no way of escaping from paying me this amount. The same was deposited to my account within 7 days after the receipt of Insurance Company’s letter at their end.  Thus, my tussle of two months fighting for my justice with the TPA ended.   My dogged pursuing paid off at last.

I came to know about such unjustified deductions in many of their Claim settlement from my immediate neighbor, friends, relatives and acquaintances. However most of them did not lodge any complaint. Even if they did, they did not follow up seriously with the TPA authorities for redressing the same. 

Please note, I only wrote several e-mails to TPA as well as Insurance company's executive and occasional phone calls to the later. I neither did ring up TPA's Head office at Pune nor their regional office at Kolkata. However I patiently waited and wrote my letters after carefully reading their letters and consulting the Policy Documents thoroughly.  The Insurance Office's Executive was naturally slow in taking actions but constant persuasion compelled him to take proper actions.

No wonder, the uneducated and less educated still think twice before doing Mediclaim Insurance.

Suggestions

I gained quite a lot experience from this incident. On the basis of that I would like to give some suggestions:

1) Don't give up your legitimate claim without giving a fight or protest.

2) Please go through the reasons of deductions made by TPA on your claim on a clear mind

3) Please study your Policy Documents thoroughly in between the lines. You will definitely find the ambiguity in TPA's arguments for deductions in your claim. Frame your reply to TPA citing the various clauses & the specific items mentioned in the policy document in support of your justification against the unjustified deduction by TPA.  Chase them regularly with their customer support team in favor of your arguments against them. If their Head office is stationed at Kolkata, then try to talk to their senior executive over phone or you may visit their office if not inconvenient for you, for lodging your protest against them.

4) Most important, please submit all the original copy of the essential documents asked by TPA in their claim form & keep a copy of all the original documents submitted to them. For convenience, please make an annexure of all the documents like a summary list & attach the same with the claim form & the documents. Take a receipt from TPA's office for the claim form & all the documents submitted to them for future reference.

5) In case of TPA's unwillingness to accept your justified explanations, you are at liberty to appeal to Senior Officer of your parent insurance company for justice. You may go to his office personally & discuss with him about your problems & hand him a letter containing all your grievances along with the necessary documents for establishing your argument.

6) Please insist on your agent to help you while filling up the claim form & submitting all the required documents. This is his duty. Don't pay heed to his tall talks & gossips about other clients. However you have to fight a lone battle to get back your hard earned money & genuine claims.

Hope this will definitely help you getting your legitimate claim amount deducted unilaterally & unjustly by the TPA. But you have to give a fight seriously & sincerely.

Note : All Cartoons used in this blog has been taken from my collection of Royalty Free Clipart CDS