NOIP Circular No 18

 NATIONAL ORGANISATION OF INSURANCE PENSIONERS

Regn No.PN 4769 (Regd under Indian T U Act, 1926)

(Affiliated to Bharateeya Mazdoor Sangh)

BMS Office, Vishwakarma Bhavan, 185, Shaniwar Peth, Pune 411030. 

 President: T.C. Gunesh Kumar Working President: Vilas V. Purkar General Secretary: Ashok J. Joshi

 Mob No: 9880683639 Mob No: 9922166599 Mob No: 9561084182 & 9945104570 

Date: 22-05-2023

Cir No 18/2023

Senior Divisional Manager 

The New India Assurance Company Ltd.

Divisional Office 120700,

8th Floor, New India Centre,

17/A Cooperage Road,

MUMBAI 400001

Dear Sir,

Re: Serious Servicing issues relating to our Group Mediclaim with TPAs

which needs your immediate attention, and necessary action

1) Original receipts

We have been receiving a lot of complaints from our members stating that, though all 

original documents and cash paid receipts are submitted along with the claim, 

deductions are being made from the claim amount on the ground that original receipts 

are not attached. This has become the most common phenomenon with all the TPAs 

especially MDIndia Ltd and MediAssist. These TPAs appear to please their master ie 

YOU, by denying part of the claim. TPAs are pretty sure that each such harassed 

claimant won’t fight out the case and resultantly their master is benefited. This is nothing 

but the blatant denial of genuine claim and this trend should be stopped forthwith. Lest 

we may be forced to raise the issue with the IRDAI. Even in case of my own claim some 

5-6 years back, same mischief was played by MDIndia with me, though I had pasted all 

the original receipts on a blank paper and had submitted. This is a great harassment of 

senior citizens like us and strict instructions may please be issued from your end to all 

the TPAs to stop this mischief forthwith.

2) KYC documents- For all cases of reimbursement of hospital expenses (not 

cashless), TPAs, especially MDIndia, have been calling for KYC documents for 

approving the reimbursement. The payment is made by the respective divisional office 

of LIC, and LIC D O maintains the KYC particulars of members/claimants. As such, 

TPAs have no business to insist on KYC for each case of reimbursement. 

Two of our members are cancer patients and every month they have to take injection, 

costing about Rs.50000. Every month when they claim reimbursement, especially 

MDIndia, is insisting KYC every month, thus creating a lot of mental agony for the 

patients. They are the policyholders under the group policy with Rs.75 lakh Sum 

Insured. By harassing like this, does your TPA wish them to die early, in order to serve 

their master? This is the most inhuman act being perpetrated on the patients who are 

already under lot of stress due to their suffering from cancer.

As such, we expect you to reign in your TPAs, making them not to call for irrelevant

requirements such as KYC. Your immediate remedial action is solicited in this matter.

3) Non-medical items-

TPA should not disallow NON-MEDICAL items of Annexure II which are

shown as payable. In many cases, they have disallowed payable non-medical items. On

pointing out the mistake, they settled it. This casual/intentional? approach of TPA

results in prolonged correspondence and harassment to claimants. Please advise TPAs

to be careful in future, else they will have to compensate the claimant by paying interest

for delayed payment.

4) Cashless hospitalization-

In cashless treatment, final settlement of Hospital bills is the responsibility of TPA, and

not of claimants. In the mentioned case, claimant’s post hospitalization claim was

withheld by the TPA MediAssist on the ground of pending final settlement of hospital

bills, claim no.113995575, TPA MediAssist. When the claimant protested and wrote to

them to settle the claim, warning of dire consequences, finally the claim was settled by

MediAssist. We request you to ensure that such incidents do not recur in future.

We are now mentioning following two cases of blatant harassment by TPAs:

1. MD 15-0029174304. The claimant is suffering from CANCER, undergoing treatment

and submitting bills for reimbursement. He was harassed by TPA by calling

unnecessary and unwarranted requirements, such as, ID PROOF or ORIGINAL BILL

OR ORIGINAL BILL DOES NOT CONTAIN BILL NO etc. Fact is that bills were original

and contain bill no. IF TPA IS CALLING ID PROOF IN REIMBURSEMENT CLAIM, IT IS

ACTING OUT OF SCOPE OF OUR MEDICLAIM POLICY AND AS THIS POLICY IS

SUBJECT TO IRDA (PROTECTION OF POLICYHOLDERS’ INTEREST)

REGULATION, 2002, IT IS COMMITTING BREACH OF THIS REGULATION. Further,

calling ID proof in case of reimbursement claim is unnecessary, unwarranted and

harassment as the claim papers are submitted through LIC DIVISIONAL OFFICE, AND

EACH CLAIM FORM IS SCRUTINIZED AND CERTIFIED THAT “THE PERSON

MENTIONED IS A BONAFIDE EMPLOYEE/DEPENDENT OF EMPLOYEE/RETIRED

EMPLOYEE OF LIC AND DETAILS OF INSURANCE COVERAGE ARE CORRECT AS

PER OUR RECORD”. (Please see the lower part of the claim form, to be filled by LIC).

The claimant protested vehemently and was compelled to lodge his grievance to PMO

GRIEVANCE PORTAL. Only thereafter, his claim was settled. It is noteworthy that

every month he takes injection costing about Rs.50000 (more than his monthly pension)

and every month he submits claim for reimbursement. And every month the TPA

MDIndia, insists on KYC. Just see the level of inhuman harassment to a cancer patient!

2. CLAIM ID 113486348, MediAssist. Claimant is suffering from CANCER and

submitted Chemotherapy treatment 40-page documents on 4.2.2023 and11.2.2023 to

TPA Medi Asst and claimed Rs.56,929/-. But TPA Scanned documents in two different

claim IDs112826773 AND 112836425. This MIGHT create mismatch and all documents

were not available for processing the claim. TPA then called those missing original

documents from the claimant. The claimant made a representation that he has

submitted all original documents but failed to convince. THERE IS A PROVERB IN HINDI ‘‘MARTA KYA NAHI KARTA’, claimant did run from PILLAR TO POST and

collected those documents again and sent them to TPA. But MISERY DOESN'T END

HERE, again these documents scanned under different ID NO.113486348 and the

claim remained unsettled. Claimant then wrote to TPA vehemently objecting, and finally

the claim was approved on 16th May 2023, that is after more than three months. There

was no requirement pending from the claimant. CLAIM PROCESSING WAS DELAYED

BECAUSE OF SERVICE DEFICIENCY OF TPA MEDIASSIST. AS SUCH, CLAIMANT

DESERVES PENAL INTEREST AS COMPENSATION FOR THE DELAY.

Above are the ‘TIPS OF THE ICEBERG’, the situation is GRIM. Our members are

SENIOR CITIZENS OR SUPER SENIOR CITIZENS. Some are in WHEELCHAIR OR

BEDRIDDEN. Some are suffering from terminal diseases like CANCER, KIDNEY

FAILURE, PARKINSON’S OR DEMENTIA etc. Hence, while dealing with their claim,

one should have HUMANITARIAN AND EMPATHETIC CONSIDERATION. We don’t

expect you to BREAK THE RULE, but careful handling of the claim, is what we expect.

We request you to look into the matter with all the seriousness it deserves, and

immediately advise all the TPAs suitably to avoid such uncalled-for harassment.

Expecting your positive response,

With thanks and regards,

Encl: Relevant documents

Yours Sincerely,

General Secretary