Remedies In Case Your Insurance Claim Rejected By Insurance Company

QUESTION: My father is 89 years old and has had recurring abdominal pain for the last few months. In April 2023, he was admitted to one private hospital in our locality and admitted for 7 days due to the pain issue.

Various tests were conducted, including blood tests, CT scans, fibroscopy, and endoscopy. No major issues were observed except some liver irregularities, and she was discharged after receiving certain oral medications. The cashless benefits are obtained through corporate TPA (EWA). However, after certain weeks, intermittently severe pain recurred for almost a week, and this time, on the first week of July, my father was taken to Kolkata at a hospital specific to liver and digestive treatment.

As advised by the doctor, he was admitted, and again, various tests are conducted, including blood and stool culture, LFT, CT scan, and colonoscopy.

But this time also no major issues were observed, and he was discharged after certain medications, which differ from earlier hospital medicines. But this time the claim is denied by TPA (EWA), stating that the admission was done only for investigation and observations and no line of treatment was done, although new medicines are prescribed in the discharge summary, and along with that, IV fluid and some other medicines were regularly given during his stay in hospital.

As TPA has denied the claim, I have to pay the entire amount in spite of paying a hefty amount of premium for my father. Can you please suggest why the claim is denied and whether there is any possibility of reimbursement of the claim by any means?

ANSWER: The denial of the claim by the TPA (Third Party Administrator) could be due to several reasons, including discrepancies in documentation, interpretation of policy terms, or classification of the treatment as investigational rather than therapeutic. To address this issue and explore the possibility of reimbursement, here are some steps you can take:

1. Review Policy Documents: Carefully review the terms and conditions of your father's health insurance policy to understand the coverage and exclusions. Pay attention to the criteria for claim eligibility and the definition of covered treatments.

2. Seek Clarification: Contact the TPA or the insurance provider to seek clarification on why the claim was denied. Request detailed information on the specific reasons for denial and ask for clarification on any policy terms that are unclear.

3. Gather Documentation: Gather all relevant medical records, including discharge summaries, prescription details, invoices, and receipts for medications and treatments provided during the hospital stay. Ensure that the documentation clearly demonstrates the medical necessity and therapeutic nature of the treatment received.

4. Appeal the Decision: If you believe that the denial was incorrect or unjustified, consider filing an appeal with the insurance company. Provide supporting documentation and any additional information that may strengthen your case for claim reimbursement. Follow the appeal process outlined by the insurance provider and submit the appeal within the specified timeframe.

5. Consult an Expert: If necessary, consider seeking assistance from a healthcare advocate or insurance specialist who can help navigate the appeals process and advocate on your behalf. They may offer valuable insights and assistance in presenting your case effectively.

6. Explore Legal Options: If all attempts to resolve the issue through the appeals process are unsuccessful, you may consider seeking legal advice to explore further options, such as mediation or legal action, to resolve the dispute.

It's important to remain persistent and proactive in pursuing reimbursement for legitimate medical expenses. Keep thorough records of all communications and documentation related to the claim and continue to advocate for your father's rights as a policyholder.

WHAT ARE STEPS TO BE TAKEN ON REJECTION OF INSURANCE CLAIMS

According to the Insurance Regulatory and Development Authority of India's (IRDAI) guidelines on standardization of general terms and clauses in health insurance, claims cannot be rejected by insurance providers after a policyholder has paid the premium regularly for five continuous years, also known as the moratorium period.

However, if this is not the case, according to IRDAI, you will have to first lodge a complaint with the grievance redressal officer (GRO) of the insurance company.

Step 1: Give your complaint in writing along with the necessary supporting documents. Take a written acknowledgement of your complaint with the date. The insurance company should resolve your complaint in any case not later than two weeks (14 days) of receipt of the complaint.

You can find e-mail IDs of GROs of all the insurance companies on IRDAI's website.

In case the complaint is not resolved within two weeks or if you are not satisfied with their resolution, you have three options:

1. You can directly register your grievance on the IRDAI's online portal, known as the 'Bima Bharosa System.'

2. Alternatively, you can lodge a complaint with the Insurance Ombudsman within one year from the date of rejection by the insurance company.

3. Another option is to file a complaint with the consumer court.

STEP 2: BIMA BHAROSA

According to the IRDAI, you can approach the Grievance Redressal Cell of the Policyholder's Protection & Grievance Redressal Department of IRADI through the following means:

1. Register a complaint directly in IRDAI's online portal, Bima Bharosa System (https://bimabharosa.IRDAI.gov.in/).

2. Send the complaint through email to complaints@IRDAI.gov.in.

3. Call toll-free number 155255 (or) 1800 4254 732.

PLEASE NOTE THAT: IRDAI prescribes a set format of complaint registration forms that can be found on its website. Further, if necessary, you can fill out and send the complaint registration form along with any letter or enclosures, if felt necessary, by post or courier to:

PLEASE NOTE THAT- However, according to IRDAI, in case the complaint is not attended to within 15 days of registration of complaint in Bima Bharosa or the resolution provided by insurer is not satisfactory, you can approach the Insurance Ombudsman as per the procedure laid down under Insurance Ombudsman Rules, 2017.

Step 3-INSURANCE OMBUDSMAN

The Insurance Ombudsman Scheme, established by the government, provides a cost-effective and impartial avenue for individual policyholders to resolve complaints outside the court system. Currently, there are 17 Insurance Ombudsman offices in different locations.

According to Insurance Ombudsman Rules, 2017, you can approach the Ombudsman if:

1. You have previously approached your insurance company, and they have rejected, not resolved to your satisfaction, or not responded to your complaint within 30 days.

2. Your complaint pertains to an individual policy, and the claim's value, including expenses, is not above Rs 50 lakh.

PLEASE NOTE THAT: Earlier, the maximum compensation that ombudsman offices could award to policyholders was capped at Rs 30 lakh. On November 10, 2023, the finance ministry amended the insurance ombudsman rules to increase the maximum compensation amount to Rs 50 lakh.

HERE IS HOW TO FILE A COMPLAINT WITH THE INSURANCE OMBUDSMAN:

The complaint must be in writing and signed by the policyholder, claimant, legal heirs, or assignee, or submitted electronically via email or through the online platform on the Council of Insurance Ombudsmen's website, www.cioins.co.in.

The complainant can send the complaint letter, along with photocopies of supporting documents, to the Insurance Ombudsman Office through post or email.

Required supporting documents include:

1. Policy copy (all pages of the policy under which the complaint is lodged).

2. Copies of all old policies covering insurance for the last 48 months before this policy if the claim is rejected based on pre-existing diseases or a waiting period.

3. Repudiation/Denial letter/Partial settlement letter issued by the insurer.

4. Representation letter sent to the insurer/insurance broker.

5. Any other correspondence exchanged with the insurer/insurance broker and TPA.

PLEASE NOTE THAT: Alternatively, the complainant can register the complaint online on the website www.cioins.co.in under the heading "Register" - Lodge"/Track Complaint Online. The required documents, proof of identification, and a photograph can be uploaded on the online registration platform.

You can track the status of his complaint by clicking the "Track Complaint" button provided under the heading "Complaint Online" on the home page of the website. A complaint can also be tracked by submitting the registered mobile number.

The Ombudsman acts as a mediator to arrive at a fair recommendation based on the dispute's facts. If accepted as a full and final settlement, the insurer must comply within 15 days, as per the ombudsman rules. Further, if a settlement by recommendation is unsuccessful, the Ombudsman passes an award within three months, binding on the insurance company. The insurer must comply with the award within 30 days and inform the Ombudsman of the same, according to the ombudsman rules.

PLEASE NOTE THAT:

1. According to the Ombudsman Rules, if there is an ongoing or resolved case related to the same issue in a court, consumer forum, or through arbitration, you cannot file a complaint with the Insurance Ombudsman.

2. You have to file the complaint before the Ombudsman within a period of one year from the date of rejection of the complaint or 30 days from the date of filing the complaint with the company.

3. The Ombudsman will declare award within a period of 30 days in case of mediation or within a period of 3 months from the date of lodge of compliant.

4. The award of the Ombudsman is binding on the insurance company, and the insurance company within a period of 30 days must comply with the award.

5. In case of delay in compliance with the award, the insurance company will pay Rs. 5000/- per day to the complainant after completion of 30 days as mentioned above and penalty interest on the balance amount.

Step 4: Consumer Forms

If policyholders are dissatisfied with the decision of an Insurance Ombudsman, they have the option to seek legal remedies. They can choose to pursue their case in either a civil court or a consumer forum.

Notably, there is no obligation for the policyholder to approach the Insurance Ombudsman before seeking recourse in the courts. They are free to directly approach the consumer forum to address their grievances.

How do I file a complaint at the consumer court?

The procedure for filing a complaint before the Consumer Court is similar to that in a Civil Court. The process begins by serving a legal notice to the insurance company. If this doesn't lead to a resolution, it is followed by submitting a formal complaint, along with the necessary documents, to the appropriate Consumer Forum.

PLEASE NOTE: The choice of the Consumer Forum depends on the amount of compensation sought:

1). Disputes under Rs 50 lakh are addressed by the District Commissions.

2). Disputes involving more than Rs 50 lakh but under Rs 2 crore go to the State Commissions, and

3). Disputes over Rs 2 crore are handled by the National Commission.

Keep these things in mind. Firstly, the period of limitation (i.e., the time within which the case must be filed in a court of law for it to be considered); this period is three years for civil courts and only two years for consumer courts, counted from the date the cause of action (i.e., broadly speaking, the grievance) arises.

DISCLAIMER: The views expressed here are personal views of the author and shall not be considered as professional advice. In case of necessity, consult with professionals for more clarity and understanding on the matter.