From : C T JOSHI,
Central Committee Member &
Chairman of MediClaim Assistance Committee,
NOIP (BMS).
To,
Sri Sanjay Paigankar,
Sr. Divisional Manager,
Divisional Office, Code: 120700,
New India Assurance Co., Ltd.,
MUMBAI.
Respected Sir,
Re : Medi Claim Cases – settled and non Settled – Covid 19 and other Claims.
At the outset I would like to introduce myself. The National Organisation of Insurance Pensioners' affiliatedto BMS has formed a Committee to help and guide gullible claimants in proper settlement of their Medi Claim dues. I have been made the Chairman of that Committee. In that capacity I am writing to you this letter as per the decision taken in the Video Conference meeting held of the Committee yesterday, on 7th October, 2020.
I am referring to you the following THREE cases, of which TWO are Covid 19 cases and ONE is non-Covid case which is pending settlement. Apart from these THREE cases I am also pointing out few earlier cases, where the TPAs have disallowed certain items, which are infact payable as per Policy Document.
COVID-19 PANDEMIC
In this Covid-19 pandemic lot of Claims are coming – both Death and Hospitalisation. Current year MediClaim Policy for LIC employees and Retirees was announced on 13th April when Corona had already come to India. But most unfortunately, no clear cut instructions, guidelines were issued either in the Policy Document or subsequent circulars by NIA. In the mean time to deal with the Pandemic almost all State Govts., have roped in Private Hospitals to treat the Covid-19 patients and fixed the cost for the same. They differ from State to State. Looking to the social importance, we expect the NIA to reimburse the Cost as per Policy Document or the State Govt., rates – which ever is beneficial to the Insured persons under the Policy.
TWO COVID-19 CASES
These cases of Covid-19 have been settled by the respective TPAs, but for far lesser amounts than the actual Claims made.
Sl No Details of the Claimant & Claim Details of the amounts not settled with our observations.
1 Sri Palekar Mangesh N
S R No:427485
Patient : Nikhil Palekar (Son)
MD Id : MDI5-0028899765.
Bills Claimed :
1) A&G Hosp: a) Pharmacy : Rs. 38,372-00
b) Lab : Rs. 14,800-00
c) Bed Ch : Rs. 30,000-00 (7500/day)
CCN:MDI5788592.
Admitted in 1)A & G Hospital,
Kalyan from 08-07-20 to 11-07-20
2) Niron Speciality Hosp from 12-
07-20 to 24-07-20.
Diagonised : Covid 19 Positive
with Sleep Apnea and
Hypertension.
SUM INS : Rs.50,00,000/-
TPA:MD India
Claim settled to Total Claim
ratio is :48%.
d) HRCT scan : Rs. 4,000-00
e) Inj. Remedisiver: Rs. 10,800-00(No recept)
------------------
Total Amount : Rs. 97,972-00
-------------------
2)Cardiac equipped Ambulance Charges for shifting from A&G Hosp to Niron Hosp : Rs.15,000-00
3) a) Hospital bill : Rs.3,05,780-00 (Niron)
b) Inj. Tocilizumb : Rs. 63,000-00(No recept)
--------------------
Total Amount : Rs.3,68,780-00
--------------------
GRAND TOTAL : Rs.4,81,752-00
---------------------
Claim Disallowed by TPA : Rs.2,50,517-00
Claim settled by TPA : Rs.2,31,235-00
1) The Claimant is not aware as to how TPA has arrived at Rs.2,31,235/-
2) It is informed to the Claimant that as per Maharashtra Govt., GR maximum amount payable is only Rs.2,31,235-00. The patient was in ICU for 11 (4+7) days, in 2 Hospitals.
3) All the Committee members of the Medi Claim Assistance Committee have gone through the Maharashtra Govt., Notification dated 21-05-2020. It is unanimous opinion of all Members, that these rules do not apply to our MediClaim Policy claims. Your kind attention is drawn to the Last para on Page 2 (before setting out 15 directions), especially the part which is in BOLD letters. Further Annexure A and B are not applicable where it is covered by Health Insurance Policy. Annexure is applicable only to 80% of the Beds, which are occupied on recommendations of State Govt., Authority.
In the light of the above, you may please advise TPA to settle the balance of the Claim amount as per Policy conditions, without further delay.
4) The employees / Retirees have opted for Higher Sum Insured, under the hope that they can admit to reputed Hospitals to get best possible treatment. Otherwise there is no need to go for Highest Sum Insured.
2 Sri R G Balambeed
S R No :551733
Patient : Smt. Geetha (Wife)
TPA : MediAssist India
MA Id:4016436145
Claim Id:101304975
Admitted in Venugram Hospital,
Belagavi on 27-08-20 to 03-09-20.
2 days in ICU and remaining days
in SemiPrivate room.
SUM INS : Rs.50,00,000/-
It was a Cashless Claim. The Hospital sent a bill for
a) Hospital Bill : Rs.1,44,564-00
b) Pharmacy Bill : Rs. 82,835-00
---------------------
Total Amount : Rs.2,27,399-00
---------------------
Claim settled for Rs.1,48,515-00
Claim disallowed :Rs. 78,884-00
1) In case number 1 above, the TPA has applied Maharashtra State Govt., set rates (although they were not applicable to our Policy), here in Karnataka the State Govt., set rates were not applied. The Karnataka State Govt., rates are mentioned below :
Rs.5200/- per day for Gen Ward under AB-ArK; Rs.7000/- per day Ward with Oxygen;
Rs.8500/- per day for ICU Isolation and Rs.10000/- for ICU isolation with Ventilators.
For other Insurance and Cash payment patients the tariff fixed are :
Rs.10,000/- per day for Insurance and Cash patients in Gen Ward;
Rs.12,000/- /day for Gen Ward with Oxygen;
Rs.15,000/-/day for Isolation ICU &
Rs.25,000/day for Isolation ICU with Ventilators.
2) We feel that the TPAs are applying those rates, which are favourable to the Insurer, instead of those favourable to the Insured.
3) For a paltry Room rent of Rs.4000/day, in Karnataka, even the Hospitals will not allow the patients to come anywhere near their hospital compound. Because for Gen Ward it is Rs.10,000/- and for Semi Private room with Isolation without Ventilator it is Rs.15,000/-.
4) That being the case the TPA / Insurer, atleast in this Pandemic, as a social obligation should reimburse, which ever is beneficial to the Insured.
ONE NON COVID CASE
Claimant : Sri R Parameswaran, Emp Id:411804. Claim No: MDI5805862. Claim amount :Rs.20,100/-
This is an ARMD case, where the amount has been increased to Rs.1,00,000/- per eye per year per member. The claim for both eyes were settled for ARMD claim for both eyes in July, 2020 very promptly. Now for second set of Injections got done on 6th & 13th August, the Claim was for Rs.20,100/- and Rs.16,600/- respectively of which the second payment has already been made. Only Rs.20,100/- is pending at the TPA end. The Claim papers have been received by the TPA MD India on 3 rd September, 2020. Reminder was also sent to the TPA by the Claimant on 16 & 30th September. The reason shown for pendancy is “Approval from Insurance Company is awaited”.
It is already more than 30 days are over since submission of Claim papers, and as per IRDAI guidelines claims if not settled within 30 days, then Interest is required to be paid.
We therefore request you to settle Rs.20,100/- immediately and oblige.
The committee also felt that since Covid-19 is a going to stay here for some more months, since vaccine is yet to come, a clear cut Claim instructions as to what is paid, how much is paid and what is not paid etc., is required to be issued by the Insurer for the general knowledge of all Insured. We hope the needful will be done by you at the earliest.
The committee has also noticed that there are many cases, where the TPAs disallow the amounts which are actually payable as per the Policy Document. We have come across many such cases, however, only a few cases are listed herein below. Because the TPAs are working for many Insurers – the terms and conditions differ widely, we feel there is a need to train the persons working in TPAs as to the terms and conditions of Group Mediclaim Policy of NIA for LIC employees / retirees and their dependants.
Keeping that in mind the following few examples are being brought to your notice.
1. 4 Claims of Sri Alok Ingaleshwar, Dev Officer, S R No:635763 of Vijayapur Branch :
Abnormal delay in settling Claims is the order of the day.
Claim ID : 101449726 Patient : Prarthana (Daughter) – Liver transplantation done 26-08-19.
Rs.40,575-00 still pending.
Claim ID : 101529397 Patient : Prarthana (Daughter)
Rs.35,858-00 still pending.
Claim ID : 101355760 Patient : Prarthana (Daughter)
Rs.51,341-00 still pending.
Claim ID : 99842419 Patient : Prarthana (Daughter)
Rs.6,800-00 balance claim amount still pending.
2. Claim ID : 96362191 Claimant : C T Joshi Patient : Smt Kanta (Mother-in-law)
Rs.50-00 GRBS charges; Rs.300-00 Canulization charges both disallowed.
Claim ID : 97848688 Claimant & Patient : C T Joshi.
Rs.700-00 : Gloves ; Rs.168-00 ECG electrodes ; Rs.595-00 Food & Beverages All 3
disallowed by TPA, although they are payable.
Rs.150/- Registration Charges disallowed by TPA but on insisting it was paid.
BOTH THE ABOVE CASES ARE OF SOUTH CENTRAL ZONE, WHERE TPA IS MediAssist India.
Further it has been reported by a member of the Committee from West Bengal that if one gets admitted in GIPSA-PPN Hospital, the Cashless facility is limited to the Package worked out between Hospital and the TPA, despite the Insured having Higher Sum Insured under the Policy.
You are most humbly requested to pay your personal attention to the above matters and take necessary action at your end and advise the TPAs suitably.
Clear cut instructions in settlement of Covid-19 cases be brought out immediately for the benefit of all Insured under our Group MediClaim Policy.
Thanking you in anticipation of a favourable action,
Yours faithfully,
VIJAYAPUR
12-10-2020. Sd/-
( C T JOSHI)
CHAIRMAN,
Medi Claim Assistance Committee
N O I P (BMS).
Mail id :joshi.chidambart@gmail.com
Cc to ED (Per), CO, LIC of India.
With a request to take up the matter with NIA, DO-120700, Mumbai.
cc to ED (E & OS), CO, LIC of India.
With a request to take up the matter with NIA, DO-120700, Mumbai.
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