Grievances of Mediclaim
Policy Holders Against PSU & Non PSU Insurance Company and their TPA’s
Sir,
This application
attempts to highlight the various unethical and inhuman practices adopted and
implemented by different PSU Insurance Companies and the TPAs associated with
them by means of carefully crafted policy conditions which deceive the policy
holders even during the critical phases of treatment. It also throws light on
the unfavorable experience
of the defrauded policy holders as well as the inconvenience faced by agents
who are assigned the task of Mediclaim Policy Servicing for the same.
We sincerely hope that
through the use of powerful reports and visual media, the common population
will be made aware of these unethical practices and if need be, sufficient
pressure will be exerted on the IRDA to revise their rules and implement them
wisely.
Please consider the
premium tariff of the PSU Insurance Companies: The policy premium is being
raised every year.The premium of the Family Floter Policy has been nearly
doubled (case in point, UIIC) whereas the benefits associated with the
Mediclaim have been cut down.
After signing up for
the Mediclaim policy, the policy holder is given a certificate along with a
booklet of the policy conditions drafted in heavy, technical terms and
deliberately printed with tiny font size. We consider it ‘Black Policy’, since they
have been devised to hide corrupt practices in the veil of Law so that the
Claims Process of the policy holders can never reach 100%.
These conditions are
implemented in such a way, that even the Genuine Claims of policy holders face
unnecessary obstacles or are denied or refuted altogether. As a result, policy
holders are unable to attain settlement of their claims and face severe financial
crises despite holding Mediclaim Policy.
According to the
conventions, the premium of a Mediclaim policy depends on the coverage chosen
by the policy holder at the time of application. If coverage of 3 lakh is
chosen, the holder is assured that their medical expenses within the coverage
will be taken care of, either by the Cashless System or by the Reimbursement
Process. But in reality, the policy holder is forced to face a lot of obstacles
positioned by the PSU Insurance Companies and their appointed TPAs, in the
shape of Capping on the hospital room rent, doctor’s bill or Investigation Bill
which hamper the Claims Settlement Process. Moreover, there exists a technical
term ‘Proportionate Deduction’. By taking undue advantage of this, the coverage
of medical expenses is cut down by almost 67%, which is unfair as well as
inhuman.
In case of United India
Insurance Co., during the Claims Process separate money receipt issued by the
doctor stating the professional fees or the charges of the team are not
accepted. These have to be forwarded through the hospital or nursing home
authorities in order to be considered for claims settlement. This is quite
ridiculous since it is a well-known fact that most renowned doctors are not
directly appointed by the hospitals. They only use the facilities or
infrastructure of these institutions for treatment. Hence, the hospital bills
and the doctor’s bills are prepared separately. How can the doctor’s bill get
forwarded by the hospital in such a situation and why should the hospital bear
the liability? So the Company steers clear of the bulk of the expense (the
doctor’s fees) and only the minor hospital expenses are covered. We must also
consider the attack on the social status of the renowned doctors whose receipts
are not accepted for Claims Settlement despite being honest and legal.
Unfortunately, repeated complaints to the higher authorities have not yielded
much result.
Another fact that has
to be drawn to attention is that the insurance companies have presently stopped
giving the legit No Claims Bonus for those holding Unclaimed Policies. So the
defrauded holders are left with no benefits whatsoever.
Several medical
conditions call for day-care treatments instead of hospitalization. While the coverage
for these expenses are denied by PSU Mediclaim Policy, several Non-PSU
Companies have stepped forward to extend their coverage in these cases as well.
PPN-approved hospitals
and nursing homes are tied with PSU Insurance Companies through fixed Package
Rates for different medical conditions, to be availed of by Cashless System.
But some institutions are illegally extorting surplus money from the policy
holders through unfair means. This is mostly done by conspiring with the TPAs
and making the patient party sign the Anexture ‘C’ form. Since the Insurance
companies won’t bear the brunt, it leads to unnecessary financial losses.
Those employed by the
Insurance Companies, ranging from officers to 4th class staff, seem
to have grown too complacent with the security of Government Service and the
lack of disciplinary action. They bear little responsibility towards the
company itself or its associated clients. They have practically no interest in
the development or growth of the business. Many employees do not even have
adequate knowledge regarding the subject. This has a negative impact on the
process of proper servicing and settlement of the Mediclaim Policies. It has
also created a huge communication gap between the Insurer and the Insurance
Company. It is necessary for the employees to understand that accepting cheques
is not their only duty. They must ensure reliable service and a healthy
relationship with the clients as well.
Often, new proposals
are not accepted if there are quite a few risks of claim. Proposals for new
policy by those above 60 years age are turned down even if there are no such
rules stated in the IRDA or Insurance Company Circular. Similarly they often
refuse to enhance existing policies. Requests for Top-Up and Super Top-Up
policies are also met with baseless excuses. This non-cooperative attitude is
counter-productive and must be eradicated at any cost.
It is requested that
the claim ratio of the Insurance company staff and that of their relatives be
brought to light. It raises a question: Do they have to face so many hassles
during their claim?
It must be brought to
notice whether the TPAs affiliated in absolutely honest ways. If so, why do so
many of them lack even the most basic infrastructure? At this point, it is
necessary to elaborate on the role of the TPAs. These are introduced to reduce
the claim ratio of the Insurance Companies and also to monitor them. The
additional 6% that the policy holders have to pay with their premium goes to
these TPAs for maintenance. Though, isn’t it quite questionable how this meagre
amount is enough to run such establishments? Actually, these establishments
have been trained to create complications in the claims settlement process. The
make use of 64 VB, Proportionate Deduction and other twisted mechanisms to hamper,
delay and repute claims.
The cards sent by the
TPAs rarely reach the policy holder in time. If they do, they are filled with
errors, be it in information or spelling. The correction of these takes up a
lot of valuable time. Sometimes, calls from policy holders are not received at
critical moments and there have been reports of misbehavior too.
There has been a lot of
doubt regarding the qualifications of the members of the Medical Teams
appointed by the TPAs to analyze the details of the claims (“Quacks” &
Homeopathy degree holders and others). As a result of this, the genuine claims
of policy holders under the treatment of qualified doctors are being challenged
on a regular basis.
The masses have the
right to know whether the Claims Settlement Process is being conducted
ethically; they also need to know whether there is proper monitoring over the
institutions by IRDA/Insurance Ombudsman/Health Department of India/Finance
Departmentof India.
Representatives are
sent by the TPAs to enquire the patients (during the course of treatment)
regarding pre-existing diseases to find out whether information had been
withheld while starting the policy. The mode of this interrogation is quite
akin to that of criminal investigation and the policy holder can get unnerved
easily, given that they are already in a weak state. Thus, the claim gets
denied without much reason.
The premium paid by a
policy holder with 1 lakh coverage is much lower than that paid by a policy
holder with 5 lakh coverage. But in several cases, the package rates for
treatment set by Insurance Companies are equal for both. Is this reasonable?
Several hospitals and
nursing homes are misusing Mediclaim Policies to add to personal profits. For
this, they resort to unfair practices in form of unnecessary hospitalization,
admission to ICU/ICCU/ITU. They also call for investigation without any
apparent need and inflate medicine bill amounts to extort the patient party.
Sometimes, patients with no hope of recovery are kept on ventilation for the
same purpose. As a result, it is becoming increasingly difficult to afford
proper treatment.
If this continues, the
system will collapse in no time. So, on behalf of numerous policy holders and
agents, we would like to plea for simplification of the Claims Settlement
Process. The process should be more humane. One-window system should be started
to make sure that the policy holders don’t have to face any inconvenience
during the period of hospitalization. It should also be assured that the policy
holders get their claims settled with respect to their chosen coverage without
capping or proportionate deduction (by actual payment basis). We hope that with
the help of powerful articles and visual media, the message will reach the
likes of Health Department of India, Finance Department, IRDA, Insurance
Ombudsman and National Human Rights Commission. We also hope that it will raise
the awareness of the masses regarding the matter
Thanking You,
Yours Sincerely,
Chandan, Uttam, Pratap
(On behalf of Policy
Holders and Agents)
Mobile no.: 9831115009,
9831609030, 9432302215
Copies of this
application have been sent to:
Honourable Prime
Minister of India
Honourable President of
India
Honourable Chief
Justice, Supreme Court
Ministry of Health,
Ministry of Finance,
Central Human Rights
Commission
IRDA
Insurance Ombudsman
IMA
Honourable Chief
Justice, High Court
Honourable Chief
Minister, WB
Dear Sir,
ReplyDeleteYou did a wonderful job.