New India Assurance has paid Rs34,313 towards a mediclaim that was earlier rejected by the TPA on flimsy grounds. The insured senior citizen has been a customer for 20 years, but that did not help to get the claim paid. Moneylife Foundation’s intervention helped
Sujit Banerjee (name changed), a retired senior citizen of 73 years, had approached the Moneylife Insurance Helpline of Moneylife Foundation seeking help with his rejected mediclaim on flimsy grounds by the TPA (third party administrator). The TPA alleged that the insured suffered from hypertension for 15 years without having any documentary support. The TPA even chose to ignore medical certificate of the illness from a doctor with super speciality degree in neurology. Inadequate medical expertise of the TPA staff has been reported by the media for a long time.
Taking the complaint to the grievance cell was the next step followed by the Moneylife Insurance Helpline in escalating the matter to the GM, grievance cell of New India Assurance. The claim was paid for Rs34,313, overturning the TPA’s debatable decision.
The case proves that TPAs should not be settling claims, which is included in the new health insurance guidelines from IRDA (Insurance Regulatory and Development Authority). Insurance companies have much more expertise on medical intricacies than a TPA. The regulations put the onus on the insurer to give specific grounds of settlement and denial of claim. In short, the insurance company cannot play the blame game that the TPA is making decisions on the claims.
Sujit Banerjee (name changed), a retired senior citizen of 73 years, had approached the Moneylife Insurance Helpline of Moneylife Foundation seeking help with his rejected mediclaim on flimsy grounds by the TPA (third party administrator). The TPA alleged that the insured suffered from hypertension for 15 years without having any documentary support. The TPA even chose to ignore medical certificate of the illness from a doctor with super speciality degree in neurology. Inadequate medical expertise of the TPA staff has been reported by the media for a long time.
Taking the complaint to the grievance cell was the next step followed by the Moneylife Insurance Helpline in escalating the matter to the GM, grievance cell of New India Assurance. The claim was paid for Rs34,313, overturning the TPA’s debatable decision.
The case proves that TPAs should not be settling claims, which is included in the new health insurance guidelines from IRDA (Insurance Regulatory and Development Authority). Insurance companies have much more expertise on medical intricacies than a TPA. The regulations put the onus on the insurer to give specific grounds of settlement and denial of claim. In short, the insurance company cannot play the blame game that the TPA is making decisions on the claims.
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