Legal action best bet for insurance refusals
29 Jul, 2014 03:03 PM
Ajay Roy, a resident of Chetla, had an eye operation in 2011 at a private nursing home in Kolkata. Roy was operated on by a surgeon not attached to the nursing home. The surgeon and his anesthetist issued a receipt. While Roy filed the case with a TPA of a public sector insurer for reimbursement, he found that the surgeon's and the anasthesist's fee was not paid. Roy was told that the insurance company would not pay for the surgeon and the anasthesist's charges unless it is included in the hospital bill.

Aggrieved Roy then approached the insurance ombudsman office in Kolkata. The insurer claimed that according to their policy conditions, bills for any surgeon not attached to the hospital cannot be paid. The ombudsman refused to accept the argument and Roy was paid the amount back.

Hazra resident Purabi Banerjee also got her dues settled within months after she approached the ombudsman office. "The nursing home made a partial payment for my father's treatment. When we challenged them at the ombudsman office, they released the fund soon," she said.

It is not Roy or Banerjee alone, but hundreds like them have won cases against insurance companies or third party administrators (TPA) after they took the legal course. "In fact, there are cases where insurance companies were ready for an amicable settlement after a notice was sent to them from the ombudsman office," said an official at the ombudsman office. A case in point is Bithika Bhattacharya, a resident of south Kolkata. A private insurer denied her any payment towards an infection on her arm. Within a few weeks of receiving the notice, the insurer agreed to pay her the entire amount.

But why do insurance companies or TPAs refuse cashless facility or repudiate a claim? According to Surendra Tiwari, chief administrative officer of Heritage Health TPA, there had been many cases in the past where claims were raised to defraud an insurance company. "There were cases where people take policies to make claims in a planned way. So TPAs are cautious in settling doubtful cases," he said.

But industry insiders feel a section of insurance companies and TPAs try to push back the case and turn the cashless facility into a reimbursement one. That is what happened to Shubhanjli Jain, who went to the US to study in Illinois University where she fell ill. Shubhanjli was covered by a nationalized medical insurance company and was confident of a cashless facility. To her surprise she found that the bills were sent to her and not to the counter part of the TPA in the US. Bills were to be paid immediately and the family was suddenly in deep trouble. Her studies came under question.

Shubhanjli's parents contacted the state consumer affairs department and the intervention was successful as the TPA sanctioned $52,270 to April Miami, its counterpart in the US.
Source : The Times Of India

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