Your Mediclaim Queries Answered

Sanjib Jha, CEO, Coverfox Insurance Broking (external link), answers your health insurance related queries.

Please mail your queries to getahead@rediff.co.in with the subject line 'Ask Sanjib' and he will answer all your health insurance queries.

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S S Tripathi: Dear Sir, Greetings of the day. I have got a health insurance of family floater type from Tata AIG for a sum of four lakhs. Recently, I got hospitalised and full four lakhs was paid by Tata Aig. But my hospital bill was six lakhs and sixty two thousand. So there was a shortfall of two lakhs sixty-two thousands. I have an Aditya Birla health Policy of family floater type for 45 lakhs. But it will come in to effect after 5 lakhs expenditure. So I myself paid one lakh from my pocket. And for rest one lakh sixty two thousand only I applied for cashless to Aditya Birla .But they denied it.

Finally I paid that amount myself and came home. Afterwards I kept continuous follow up with them. Reconsideration and reminder letter was sent by TPA and Treating doctor. But again it was rejected. Now Aditya Birla employee is saying apply for reimbursement.

When Tata Aig is clearing full amount, how come Aditya Birla is denying it? And how can I bridge the gap one lakh between two policies? Tata Aig says you have taken full claim so we cannot make your limit from four to five lakhs this year. Pls advise suitably. Best Wishes

Sanjib Jha: Hi Mr. Tripathi, greetings to you. To answer your first question as to why Aditya Birla won’t provide you with cashless claim as opposed to TATA AIG is because the policy you bought from Aditya Birla is a ‘Super top up plan’ which basically means it is an addition to your base policy which in your case is your TATA AIG policy.

Super top up policies do not offer cashless claims but only provide reimbursements.

The one lakh gap, unfortunately, cannot be filled at this point. However, while renewing your policy you can opt for increased sum insured with TATA AIG. The insurer will ask you a set of questions and schedule medicals to analyse your risk profile. Post that based on your reports, the insurer will take a decision on increasing the limit.   

Thangavelu: My family (aged 54 years) is covered under ECHS (Ex-servicemen Contributory Health Service) for the last thirty years. I have family floater health hospitalisation policy in two different insurance companies. Three years back, she had some issues related to her blood disorders. During the blood transfusions, we have made claims in the insurance cover.

It took few months to diagnose the issue. Finally it was diagnosed as 'a type of blood disorder'. I have availed the hospitalisation and treatment facilities from ECHS.

Now she has recovered (and under medication) for the last two years. She is leading normal life. My query is:

Can I declare and have Critical illness included coverage in the health insurance? (Earlier I was denied as permanent exclusion -IRDA).

Can I continue the existing health coverage from the insurance from other than Critical illness? (I can get ECHS facility, but there are limitations). Since she is alright, will the insurance companies accept? We are ready for relevant medical tests as required.

We seek your advice.

Sanjib Jha: Hi Thangavelu, good to know that your wife is doing well. To answer your first query, yes you can declare your critical illness and avail the rider for it. Another option is to purchase a new plan for critical illness from an insurer of your choice. The insurer will ask a set of questions and based on that the coverage will be provided. However, most of the insurers will keep the PED in the Permanent exclusion list. As far as your query on continuation of policy is considered, you can continue with the existing health policies you have.

Any medical condition which arises after the waiting period of the policy will be covered in the health policies. Which is why check for the waiting periods associated with different ailments in your policy document.

Ashok Maheshwari: I am 83 and hale and hearty. My only passion is TRAVEL -- National and International. I have a daily routine to go for morning/evening walks along with light exercises at home.

At the age of 76, I had IMPLANTATION of PACEMAKER and thereafter CABG.

Health Insurance: No insurance company offers me a comprehensive Health policy with ADDS ON. I am offered HEART POLICY without ADDS ON like day care treatment, but EXCLUDING PACEMAKER.

For this, their Premium is Rs.74000.00.

I have no problem whatsoever as far as my Heart and Pacemaker, then why the insurance company can't include day care treatment.

It's quite shocking that in our country, Health insurance is HARD CORE BUSINESS and IRDA and Govt. of India is aware of the happenings in Healthcare Insurance but keep their eyes closed. What a Pity!

Sanjib Jha: Hi Ashok, it is great to know that you are maintaining a healthy lifestyle and living your life to the fullest. The concern raised by you is legit but the solution to it is simple – Buy the right kind of health insurance policies at an early age. When one purchases health insurance at an early age, the premiums they pay will be lower because their pre-existing diseases will be lesser and will not be considered a high-risk profile.

As our age increases, the chances of health deterioration increase which makes the premiums higher and in some cases a lot of diseases and ailments come with a longer waiting period and PED exclusion lists. During the time of issuance, each insurer analysis the risk via proposal form, medical reports and take decisions accordingly.

Age is an important factor in risk determination by the insurers and considers old age applicants as very high-risk profiles and hence doesn’t provide health policy. Few of the heart policies as said will provide coverage but will exclude the PEDs (pre-existing diseases).

This is why the Govt. of India, IRDAI, Insurers and broking companies like Coverfox Insurance are trying to educate the masses to purchase health insurance policies at a younger age and are constantly trying to inform people of the benefits of Health Insurance and how to choose the correct plan for oneself.

Jyoti Swaroop Pandit: I have mediclaim policy from Oriental Insurance Co since 1992 for 5 lakhs and other from New India Assurance for 7.5 Lakhs under SCUM scheme with my spouse. However both the policies have set a limit of Rs. 40,000 for Cataract surgery even though I have been diagnosed with 1) Cataract Phaco with Panoptix IOL, 2) Pupilloplasty, 3) CTR Implantation for which a renowned hospital billed me as below for separately for each eye.

1) Cataract Procedure Cost. Rs. 27000/- which is approved by Oriental in their contract with Hospital

2) IOL Cost Rs. 49000/-

3) Pulilloplasty Rs. 6950/- after discount

4) CTR Implantation Rs. 1600/ after discount

Now in Claim No. 1 Oriental approved. Rs 36,000/- Only and balance Rs 48500 I had to pay

Claim No. 2 Oriental approved Rs.73,300/- Only and balance Rs.11250/- I had to pay

Surgery was done 1 week apart.

In my case I was advised Cataract with multifocal IOL + Pupilloplasty + CTR Implantation

So, I need your advice on:

How can Insurer Oriental approve and give different claim amount for each eye and how can I claim for reimbursement of balance amount I had to pay. Appreciate your guidance and help.

Sanjib Jha: Hi Jyoti, hope you are doing well. As you have mentioned that the claim amount for each eye has been different, to understand the reason behind this disparity, you will have to check the documentation submitted to the insurer for both the surgeries. Request you to contact your insurance advisor and discuss the same with the insurer to understand this gap further and help you resolve this issue.