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Moneylife Personal Finance Insurance Cashless Mediclaim: A real-life story & Moneylife guidehrough the maze

Cashless Mediclaim: A real-life story& Moneylife guide through the maze

AJ PRADHAN | July 13, 2012 01:10 PM |

Insurance is easy to buy but tough to claim, if you are an individual. Raj

Pradhan narrates a real-life story that takes you through the labyrinth of

nsurance company, broker, TPA and hospital to explain how to make a valid

claim and how to avoid going out of pocket

The point about insurance, in fact the very purpose of buying it, is defeated, if your claim

s rejected. Only those who have been through the hard-knocks of getting a claim paid,

know how complicated it is for those who do not have corporate support. The best way to

understand the complexities and pitfalls is to take the reader through a real-life example

of what can happen, even in the best case scenario. And, indeed, this case is probably as

good as it gets. It pertains to an office assistant at Moneylife, Rajesh Juwale. The case was

personally handled by thiswriter, who has studied almost every aspect ofthe insurance

business in depth. Moreover, Moneylife has an excellent equation with the insurance

PERSONAL FINANCE INVESTING MARKETS COMPANIES & SECTORS ECON


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companyand the broker, with direct access right to the top, which ensured that we were

guided well and the process was smooth. Yet, there were plenty of learnings for anyone

who is under the illusion that buying the right insurance is the critical decision.

Rajesh suffered pain in the abdomen sometime in early

April 2012. A quick visit to his doctor led to the

administering ofan injection and a recommendation of

sonography which revealed a 16mm kidney stone. Rajeshs

first instinct was to avoid surgery and opt for ayurvedic

treatment. The pain stopped, but another sonography a

month later revealed that the stone was intact. We explained to him that our group

mediclaim would allow him to get proper allopathic treatment.

Moneylife has a mediclaim arrangement with Bharti AXA General Insurance with no

waiting period for pre-existing disease (PED). Such an option is available only for groupcovers and not on individual policies. Interestingly, this is the first time in over three years

of taking the group policy that any of our employees was going to avail of mediclaim; and,

t was our first year with Bharti AXA. As the insurance specialist at Moneylife, I was

assigned the task of hand-holding Rajesh through the process. It was also a first-hand

earning experience for me.

Our first challenge was to find the right hospital for the procedure (from the list of

approved ones provided by the insurer or others). We got our first exposure to whynsurance costs in India soar, right away. We had excellent options nearby which would

have provided good, clean and cost-effective treatment. One was a well-known large

hospital at Dadar and the second a smaller private hospital with a good reputation. But

neither of them would accept a cashless procedure. This meant one of three options. First,

he hospital would have to put funds at risk by paying for the procedure and wait for the

claim; second, Rajesh would have to pay the costs and claim insurance, which at a

multiple of his monthly income was simply unaffordable; and third, look for a more

expensive alternative which provided a cashless facility. We were guided to one.

*Our first learning was that some good, cost-effective hospitals do not want the hassle of

dealing with TPAs (third party administrators) or delays in payment by insurance

companies. While many TPAs usually allege that hospitals are dropped from the list

because of inflated bills or erratic services, nobody ever discusses payment issues and

delays on the part of insurers or TPAs. Since the cost is borne by insurance companies, it

s for them to consider that they eventually pay twice as much for non life-threatening

ThsuplaGeLebro


3/17

procedures, only because smaller, cost-effective hospitals feel harassed by the claims

process and have opted out.

We were informally guided by our broker to consider a kidney stone speciality hospital

RG Stone, Khar, Mumbai) which was on Bharti AXAs approved list. While we zipped

hrough the process, it was soon clear that an ordinary individual, especially not a very

iterate person like Rajesh, would be all at sea. In fact, negotiating the process of applying

and getting insurance without a hitch needs to be approached like an assignment, with

one person in the organisation or the family taking full responsibility. Here is why.

Confusion over Rules and Procedures

* Our second lesson was that brokers are also not very savvy about the rules and you need

o know them yourself. For instance, we were first told that service tax is applicable for

cashless facility and it has to be paid by the person insured. This would have been a blow,

ince the service tax component alone would have been nearly equal to Rajeshs monthlyalary. Neither he nor the office could have afforded this additional outgo. With a little

research we found that a finance ministry notification had scrapped the service tax from 1

May 2011. That it was imposed in the first place reveals how thoughtlessly tax policies,

especially those related to service tax, are being framed.

Next, wewere told that application for cashless procedure was to be made only on the day

of the procedure. Since we didnt want to risk a rejection and since it was a planned and

non-emergency surgical procedure, we insisted on prior approval. Here again, had webelieved the so-called experts, we would have ended up with costs and delays or

additional payments because of needless confusion. It would also have left the patient at

he mercy of the TPA or, as in our case, a postponement (we were unwilling to cough up

cash upfront) of the surgery. The important lesson here is to always get prior approval for

planned procedures, irrespective of what the TPA or agent may tell you. It is only in an

emergency that you dont have a choice.

Not Quite CashlessPre-hospitalisation Expenses from Your Pocket* A third learning was that even if you have a cashless facility, the cost of registration as

well as initial consultation and tests have to be borne by the patient. These are expensive

n a speciality hospital and negligible in small ones. But since the latter are usually

unwilling to offer cashless facility, it is a double whammy for poorer or middle-class

patients. The cost of consultation and tests are usually reimbursed by the insurer

provided that a procedure is, indeed, recommended and done. (Mediclaim without

outpatient department cover is reimbursed only if it leads to any medical procedure.)


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* Our fourth learning was about finding out the cost of procedures and tests. Hospitals do

not offer simple online charts with the approximate cost of various procedures (many

arge hospitals do have voluminous charts with cost of various services, including rooms,

doctors fees and charges for various tests). But it is impossible to arrive at even an

approximation of the likely cost or what may be outside the insurance claim, based on

hese charts.

Social activist Gaurang Damani, who has filed a public interest litigation in connection

with insurance, says, Rate chart should be prominently displayed at the hospitals. This

may be the domain of Medical Council of India (MCI), but if Insurance Regulatory and

Development Authority (IRDA) can instruct insurance companies to deal only with

hospitals that provide rate charts for full treatment packages, that would be great. If

package rates cannot be displayed since they may not be standardised across insurance

companies and hospitals in a particular geography, rate chart can be conveyed to theconsumer in the insurance policy document. There is a lot of randomness in these rates.

n our case, we had the opportunity to check RG Stones charges at two different locations

n the same week. We found that the doctors consultation fees at RG Stone Khar was

Rs700 and we paid Rs3,000 for an IVP (intravenous pyelogram), while RG Stone, Mira

Road (a Mumbai suburb, where RG Stone is a part of the Bhaktivedanta Hospital) charged

Rs400 and Rs2,700, respectively. One reason could be higher realty rates at Khar, but it

hows that you may pay different rates even in a branded chain for the same service. Ofcourse, this does not affect a patient who has an insurance cover but what does such

randomness do to healthcare costs?

After the mandatory tests and examination, the very warm and helpful doctor at RG Stone

explained his condition to Rajesh and recommended two alternative procedure options

PCNL (percutaneous nephrolithotomy) which needed two days of hospitalisation or

ESWL (extracorporeal shock wave lithotripsy), an outpatient procedure. The doctors

preference was for PCNL (because the stone was big) and he pointed out that the ESWLmay need multiple sessions.

nterestingly, the cost difference between the procedures was more than 70%. According

o the TPA desk at the hospital, the cost would be Rs56,470 for PCNL versus Rs32,500 for

ESWL (maximum three sittings). Again, the cost of expensive procedure option is borne

by the insurance company. We tried to ascertain what their thoughts are.


5/17

Dr Amarnath Ananthanarayanan, CEO and MD, Bharti AXA, said, As the choice of

hospital is a patients prerogative, there is no compulsion for the patient to opt for a

particular hospital. Generally the patient opts for the hospital based on the doctors advice

especially in surgical cases involving specialist surgeons. So in most cases the hospital

choice is independent or irrespective of the hospitalisation charges. The approval from the

nsurance company normally would be on the basis of the room rent as well as the costs of

reatment in a particular hospital apart from what would be covered under the terms of

he insurance policy that the customer holds.

Shreeraj Deshpande, head of health insurance Future Generali, said, The amount

payable for cashless treatment is decided on the class of hospital and the city it is located

n. The differences in the procedure cost arise due to the higher charges of room and

urgeon charges. The hospitals have differentiated tariffs for their room types and, hence,

he insurer would be aware of the same at the time of taking the hospital on the network.

As long as the hospital adheres to its published tariff or negotiated rates, we do notquestion them.

Dr Damien Marmion, CEO, Max Bupa Health, said, We have detailed Service Level

Agreements (SLA) and negotiated tariffs with clear understanding of the non-payable

tems. We dont have exclusions on different procedures, so long as they are related to the

ine of treatment. If the customer chooses a network hospital that is more expensive then

we would pay the higher expense.

Antony Jacob, CEO, Apollo Munich told us, In India, we do not use any scientific

methodology for grading providers to determine the quantum payable. This is based on

experience of reasonable charges for a particular type of provider.

A better system of estimating charges may actually help insurance companies, because

many of those insured would be able to opt for lower cost options, simply because of their

amiliarity or proximity to place of work. Not everybody who has a valid insurance policy

wants an expensive five-star hospital but, in the absence of adequate ground work bynsurers, people are actually nudged towards more expensive hospitals.

n our case, the tests and consultations happened in one sitting. We had to pay the

upfront charges of over Rs4,200 (including medicines). The TPA told us that registration

and non-medical charges imposed by hospitals would not be borne by the insurance

company. Further, we found that some hospitals insist on a cash deposit from the patient

even if a cashless procedure is approvedjust in case there are complications or need for


6/17

extension of hospital stay. We were fortunate that neither was required at RG Stone. But it

s another factor that needs to be kept in mind while opting for cashless group insurance

here are many costs that are outside the claim and can tot up to a neat sum that may be

beyond the means of all employees. Although RG Stone had none of these charges or

demands for deposits, they did ask us for a blood cross-matching and reservation which

cost a few hundred rupees and had to be done at a separate facility, the cost of which was

not covered by insurance.

The key here is to know that there will be many such costs that would need to be borne by

he patient which are impossible to estimate even while opting for a cashless procedure.

These costs are higher when the hospital is fancier. For the patient, it is a Hobsons

choiceyou can opt for a less expensive facility (save the insurance company money),

orgo cashless, but still be penalised by way of not getting a full reimbursement. Or, you

can go to a more expensive facility, where the bulk of expenses are cleared under the

cashless facility, but the extra charges/fees and costs, that are not included in the cover,could be very steep for employees lower in the organisational pyramid.

Smaller companies who offer mediclaim to employees must know that they will have to

bear these costs as a medical advance to the employee, until the insurance claim is paid.

But we are not sure if insurance companies, looking to expand their footprint, have

examined these operational issues or attempted to find solutions in their own interest.

Enter the TPAThe TPA desk (RG Stone Hospital employee) filled up the cost of treatment to be

ubmitted to Paramount TPA for clearing cashless treatment. It was Rs52,470 + Rs4,000

ncluding a room as 1% of the sum insured. But instead of an instant approval, there were

a couple of additional wrinkles. The TPA desk, which probably fills out requests for

clearance day-in-and-day-out, had omitted to provide a break-up of Rs52,470 while the

extra Rs4,000 was lumped under miscellaneous and the TPA (Paramount) raised a

query.

When the approval did come in, it was only for Rs52,470. We were clear that Rajesh was

not going to pay the miscellaneous Rs4,000, nor would Moneylife. More frantic phone

calls to the Hospital and TPA followed and we learnt that Rs4,000 was for Cystoscope

camera) used during the surgery. Since the camera was reusable, the insurer was

correctly willing to pay only the rent for it. This was sorted out quickly. The TPA desk at

he Hospital told us that the procedure would be done within the sanctioned Rs52,470

and we would not have to pay for the camera. We have no idea what that was about, but


7/17

he fact is that we did not pay; we dont know if it was due to our direct access to Bharti

AXAs top management. Would someone else in our place have had to cough up Rs4,000

or a camera that the hospital uses once and keeps it? We believe so.

Fortunately for us, the surgery went off smoothly and we are happy that the insurance

also covers the post-operative procedures such as stent removal, sonography and

medicines which are required to be done a month later. Our final takeaways from this

experience are:

1. Mediclaim usually covers treatment that requires 24-hour hospitalisation with a few

exceptions. Some insurers, however, cover day-care procedure like lithotripsy. More and

more day-care procedures are covered in mediclaim due to technological advancements

hat do not need 24 hours or more of hospitalisation. You need to be aware of them.

2. Claiming insurance money is a fairly tough process. If it is not an emergency, it is worthyour while to spend time to learn, ask plenty of questions and make an appropriate

choice.

3. Ideally, go for cashless in a pre-planned procedure. It eliminates nasty surprises on

what the insurance company is willing to pay.

4. In case of reimbursement, Bharti AXA allows patients to get an estimate of costs before

he procedure and submit it to the TPA prior to the procedurethey will give you anassessment of what can be claimed and the final payment would be more or less than the

estimate. Future Generali India Insurance gave us similar feedback. However, not all

TPAs will provide you the approximate costs. Max Bupa Health was clear that, given the

complexity of procedures and expenses, they would not be able to give an indication

unless all papers are submitted. They also recommend opting for cashless treatment.

Apollo Munich had a similar view. Under the garb of reasonability in charges (without

clearly stating so), the reimbursement may be trimmed, to your dismay. Insurers can also

deny on the technical ground of delay in receipt of hospitalisation intimation or claimubmission, even though IRDA circular clearly states that claims should not be

mechanically denied on violation of timelines. Moreover, there could be delay in payment,

depending on your insurance company. We came across a horror story of an insurer who

ook almost one year to reimburse a cataract claim payment. IRDA draft guidelines state

hat claim payment should be within 30 days of submitting all the documents, but it is not

yet implemented.


8/17

5. If the day-care procedure you intend to undergo is not specified in the policy wordings,

t is a grey area. But, dont lose heart as you may be able to persuade and prevail. A lot will

depend on the negotiation power of the intermediary. Group policies carry more weight; a

good intermediary can prove to the insurer/TPA the medical nuances of the procedure

hat will actually help the insurer due to lower cost than regular procedures that need

hospitalisation.

6. If the insurer/TPA brushes you off, you can still seek justice at the Ombudsman or a

consumer court. If you purchased mediclaim in good faith and are convinced that the

nsurance company should pay, go for the fight. In a recent decision from the consumer

court, Oriental Insurance Company was told to pay medical expenses of Rs93,800, with

9% interest from August 2010 along with compensation of Rs9,000. The insured, Abhay

Bharad, had approached the consumer forum after the insurer refused to reimburse his

expenses for radiotherapy treatment for a knee ailment which involved 21 daily sittings

and not hospitalisation.

7. Remember, there are always costs involved even in cashless (registration, tests,

deposits, incidentals and, strange costs like those for a camera); it is better to try and get

an estimate of these costs before choosing where to get yourself treated.

8. Insurance advertisements make it appear that insurance is easy to buy and easy to

claim. In reality, the claims process is tough to negotiate, especially for those who are less

educated.

9. Finally, be meticulous in your paper work and dont, under any circumstance, delay the

ubmission of the claims request.

10. The difference in the cost of diagnostic tests is enormous. A television show has

recently exposed the kickbacks involved in these recommendations. So put your foot

down if needless and repetitive tests are prescribed. Also, shop for good places that offer

he same investigation at lower costs. In our case, Rajesh was charged Rs900 for oneonograph, but paid just Rs350 for the second one at Navneet Jain Health Centre, at

Dadar, Mumbai.

11. Medicine costs can also upset budgets. Some pharmacists offer discounts ranging from

5% to 10% to regular users. Moneylifes Cover Story (9 September 2010) has already

reported wide variation in the prices of branded medicines and not just branded versus

generic.


9/17

12. Rajesh was prescribed Cetil 500mg (Cefuroxime) which costs Rs264 for four tablets.

Low-end Cefuroxime branded Forcef (Aristo) costs Rs206 for four tablets, while high-end

Ceftum (GSK) costs Rs332 for four. Alevo (Levofloxacin) which was also prescribed costs

Rs44 for five tablets. Low-end Levofloxacin branded Leeflox (Centaur) costs Rs37 for five,

while high-end Tavanic (Aventis) costs a whopping Rs475 for five! It is, indeed, tough to

get into such detail. Hopefully, somebody will help create a web resource for checking

comparative prices at least for those who are net-savvy.

Cashless Approval What Turnaround Time (TAT) To Expect?

Bharti AXA works with TPAs. CEO Dr Amarnath, says, Cashless approval TAT takes

anywhere between two to four hours after receiving the complete information; it is 24x7

round the year in case of an emergency. Our experience was that it took longer, and was

not wrinkle-free, due to incomplete submission by hospital TPA desk.

Max Bupa Health does not work with TPAs. According to CEO Dr Damien Marmion,

Cashless approval can take four hours from the time of complete request. Our cashless

authorisation team works 24x7. Infrastructure limitations at the hospital can extend the

ime till the next day as hospital TPA desk closes in the evening.

Apollo Munich works with one preferred TPA (Family Health Plan) which has a

dedicated unit. Its CEO Antony Jacob, says, Apollo Munich has a turnaround time ofapproximately two hours.

Future Generali India Insurance has set up an in-house claims department last year

which is appreciated by many. They dont work with TPAs any more and this is a growing

rend. CEO Shreeraj Deshpande says, The average time for processing a cashless

complete in all respects is 30 minutes from receipt of information. We work 24x7

rrespective of any public holidays. He too says that further delays, if any, are due to

hospital TPA desk not working 24x7, on weekends or public holidays.

TPAs recommend that you keep aside 2-3 days for cashless approval of pre-planned

procedures to ensure all queries are resolved.

Emergency Hospitalisation


10/17

ts a running movie in a fast-forward mode. In case of emergency hospitalisation, it is

best if you and your family are prepared to work in an organised manner. Here are a few

ips:

Know your insurer/tpa, broker/agent. Have all the contact details. Confirm with the

ntermediary the role they will play in case of your medical emergency.

Understand what is covered and not covered. Ideally, find out things when there is no

emergency! Ensure that there is no change in policy wording during renewal.

Keep mediclaim policy documents, policy ID card, updated cashless hospitals list,

nsurer/TPA phone numbers, email and postal address in a place accessible to your family

at home and even during travel. The postal address is needed for pre-and post-

hospitalisation expenses reimbursement for cashless treatment.

Photo identity proof (passport, drivers licence, PAN card) of the insured are needed

during cashless application and reimbursement claim submission.

Research the local hospitals and nursing homes. Narrow down to one or two hospitals

which offer cashless as well as facilitate most of the medical procedures. Check the TPA

desk at these hospitals and get their contact information.

Keep all medical reports, pharmacy bills, lab/diagnostic bills, etc, to establish a trail foryour medical need. It is required for cashless approval and claims reimbursement. Keep

photocopies of all the documents before submitting originals to insurer/TPA.

Be ready to pay for incidentals (that may or may not be reimbursed). Keep emergency

cash at home as it may be needed even for cashless treatment. Registration and non-

medical expenses are not covered.

Co-payment and No-frills Mediclaim: Will it be win-win for insured andnsurer?

When mediclaim policy offers cashless at high-end hospitals like Hinduja, Lilavati, etc, in

Mumbai, it is tempting for the insured to indulge in the best of medical treatment even for

non-life-threatening procedures. There can be a huge variation in costs among different

hospitals for the same procedure. The insured may not worry, as making a claim is looked

at as payback time for getting the benefit of premium payment over a period of time. The


11/17

nsurer pays the claim but, ultimately, the insured pays with possible increase in the

premium.

Co-pay means that the insured is required to bear a certain percentage of expenses

ncurred on the hospital bill. For example, if co-payment for a procedure is 30%, it means

he policyholder will pay 30% of the procedure amount while the insurer will pay the

balance. Health insurance claims data shows that as the sum insured (SI) increases, so

does the average claims size. Co-payments bring partial responsibility of payment and,

hence, scrutiny as well as possibly negotiation of hospital charges by the insured. Are co-

pays the new weapon to fight excessive hospital charges and an answer for making the

nsured responsible?

The co-pay clause is applied in different ways by insurers. Some may apply it when a

policyholder gets treatment in a non-PPN (preferred provider network) hospital. In some

cases, co-pay may be applied only to certain ailments specified in the policy or medicalexpenses related to pre-existing conditions. Others may insist on co-pay if the

policyholder undergoes treatment in certain metropolitan cities.

Check out how the co-pay is applied in your policy, as it may even be subtly applied in

conjunction with room rent. In this case, you will not see the word co-pay in the policy,

but it works in a similar way. Some policies pro-rate the claim based on your room rent

and actual room you availed. For example, if the room rent limit is 1% of SI and assuming

SI of Rs2 lakh, your room rent limit is Rs2,000 per day. In case you avail a room ofRs3,000 rent, your full claim amount is pro-rated to pay only 2/3rd of the claim. The

remaining 1/3rd will be borne by the policyholder.

The main advantage of co-pay to the policyholder is a lower premium. Higher co-pay may

ower the premium. Unfortunately, the co-pay clause is rife in senior citizens mediclaim

where premiums are not low. It means that the age at which you need medical facilities

he most is when you will also have to bear the burden of hospital bills partially. Star

Healths Senior Citizen Red Carpet policy has 50% co-pay for PED and 30% co-pay for allother claims.

Some insurance companies, including Bharti AXA, are looking to launch no-frills health

nsurance covers. No-frill policies may have lower limits on hospital room charges, disease

wise coverage limit or limited choice of hospitals one can go to, to avail both cashless and

reimbursement facilities. According to Bharti AXA, The aim is to give the aam aadmi a

product that is affordable and provides maximum benefit at minimum price. One of the


12/17

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Comment32 Comments

SANJAY PSINGHANIA3 days ago

THANKS TO SHARE THE INFORMATION. ONE QUESTION HAS ARISED AGROUP MEDICLAIM POLICY OF MY MAMIJI FOR CLAIM REJECTED THATTHE DISEASE WAS PRE EXISTING , EVEN THEY HAVE REJECTED THEDOCTOR'S LETTER THE PROBLEM WAS DIAGNOSED AFTER THEADMISSION OF PATIENT, WHERE SHOULD WE FIGHT FOR THE SAMEPLEASE ADVISE MESANJAY P.SINGHANIA+919223244214

[email protected]

Reply Link Report abuse

ekta thaker3 days ago

I am very fortunate to receive this kind of email specially when one of my bestfriend is suffering from the same problem and yesterday only she asked me for thehelp. She has fibroide problem problem and ins co through which she has takenmediclaim refused to pay claim for the operation but , hospital says they have done


14/17

same operation many times and now they rejected the claim . So thanks a lot toyou Mr. Raj for giving such wonderful and full of knowledge article on the same.


raj3 days ago in reply to ekta thaker

you need to see the policy wordings, exclusions for specific period, number of

policy years, pre-existing, etc. If it looks fine, you can approach grievance cell ofthe insurer and then Insurance Ombudsman.


Prem Panjwani3 days ago in reply to ekta thaker

see the policy condtion it is not covered for first two years it is called hystrctomy


anantha bhaktha3 days ago

Thanks and a very good pice of info.

please check this website for comparative prices of medicines ..

http://www.medguideindia.com/


manish n shah4 days ago

Thanks,very good article,now in your report, you stated that central government havewithdrawn service tax, please give more details, as paramount tpa(reliance gic),where my claim is pending are duducting service tax charged by hospital from myclaim amount, pl reply,manish n shah([email protected])


raj3 days ago in reply to manish n shah

as specified, service tax for cashless is removed from 1 May 2011. If your claim wason or after this date, you should not have to pay service tax



15/17

manish n shah23 hours ago in reply to raj

MY QUERY IS RELATED TO SERVICE TAX ON ROOM CHARGES FROMHOSPITAL,AND MEDICLAIM TPA IS DEDUCTING SERVICE TAX FROMCLAIM


MOHAN SIROYA5 days ago

Dear Mr. Raj Pradhan

1. At the outset, I appreciate your detailed reportage about the actual difficultiesfaced by an Insured person due to 'inbuilt' lacunas partly but mostly I would saythe lack of Fighting Spirit or the 'Surrender Attitude'of the Consumerorganisations or individuals alike.2.First and foremost is, the IP must clearly imbibe what is specifically written inthe policy or 'in between the lines' some times an 'Hidden intent. I am not aware, ifyour group policy inder which this case arose, specifically exculded the"Registratioin /Admssion Charges'for the Hospitalization. If not, it is the generalmalpractice of the Insurers to simply reject this charge as "not admissible underthe policy. For such refusal we must fight . Ask , to point out the 'Exclusion' if it isprovided in the policy terms. If the IC fails to point out, the IP must challenge itbefore the Insurance Ombudsman. Recently, in one case I had , and I recd. theRegd. charge subsewquently. In another rejection claim also I am challenging it.3. As far as the present 'Individual 'Policies are concerned , it does clealy mentionsas 'Payable' . I have a policy from NIAC and last under the exclusion clause, itexcludes "Service charges or any other charges levied by Hospital, exceptregistration/Admission Charges".Let us ask a simple question . If the mediclaim reimbursement is meant for onlyHOSPITALIZATION, then one must first get admitted in the Hos.How can one

will be deemed admitted unless the pre-requisite of Registration charge iscomplied with ? And if so, ipso facto such a charge has to be accepted as alegitimate hospitalization expense as a part of treatment.4. Your point about the rate chart is most valid. But then this is laxily of law andlack of implementation. IMC even prescribes for display of 'Consultation Fee" byall Consultants to make the patient aware beforehand to decide about theconsultation. But I have yet to see this by any Private or Public Consultant havingdone . The patients have no alternative to withdraw since the 'Arbitrary High Fee'is paid after the Consultation is over. Even if it is taken beforehand, no where thecharge is indicated but only orally mentioned. ALL SUCH CASES OFPRACTITIONERS have to be reported to MCI and of the Hospitals to the IRDA , if

any Insuracne is involved as RE-imbursement.5. Yes, IRDA guideline to the Insurers directs to settle the claims within 30 days.But it does not have any penal provision for not obeying this guidelne by ICs.Thus, ICs are indulging in the malpractice with impunity at the cost of IPs. Theblame solely be attributed to IRDA inaction for such delays.6. I can not understand how the price of the same branded drug can differ fromone shop/place to another ,unless the manufacturing period was different andinbetween the NPPA permitted the price to be enhanced.7. Yes, we must have the recourse to buy the equivaalent 'Generic Drug' to save thecost against the branded drug. But then for that we must ,before hand ask our own'Doctor' the alternative generic ingredient for the prescrived brand.


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Mohan SiroyaConsumer Acivist and Chairperson-- Consumer Complaints Cell


mahendra mehta2 days ago in reply to MOHAN SIROYA

dear sir

my contact detail is as follow

[email protected]

09322597043.

pl send me the detail of IRDA and insurance ombudsment office in mumbaiandheri .


mahendra mehta2 days ago in reply to MOHAN SIROYA

dear sirpl give me your contact detail .i need to know the next step for my rejected claim of medclaim police .in mumbai andheri where i can go to consumer court ?also after rejection BY the TPA-TTKI want TO go for the consumer court but not aware of the step . if you can help methen it will be very much useful to me .


raj4 days ago in reply to MOHAN SIROYA

Agreed with your points. Point# 6-The difference in price is between differentbrands (differnt pharma companies) for same drug. Moneylifes Cover Story (9September 2010)gives many examples.


MOHAN SIROYA3 days ago in reply to raj

Have replied to this already .


MOHAN SIROYA3 days ago in reply to raj

Yes, for different brands ,the price difference is there. That is because, just to

charge more,the Drug co. either ads a miniscule quantity of some other drug to the


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main ingredient ,which neither enhances notr reduces the efficacy or the drug isoutside the Price Control of NPPA.That is why the stadardization is lacking.Mohan Siroya


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