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 General Secretary: Ashok J. Joshi
Mob No: 9880683639 Mob No: 9561084182 & 9945104570
Date: 04-02-2025
Cir No 6/2025
The Executive Director (Per),
LIC of India,
Central Office,
Yogakshema,
Mumbai
Dear Sir,
Re: Mediclaim/TPA related issues.
This is further to our letter dated 22.1.2025, suggesting improvements/additions in Group
MediClaim policy for the year 2025-26.
It has come to our knowledge that the meeting of all TPAs and NIA Ltd (our insurer) is scheduled
to be held in Mumbai on 7th February, to discuss the issues faced by the insured regarding claim
settlement etc. NOIP has been writing to you regarding various issues faced by our members
regarding claim settlement etc. It would have been proper to call our representative also to put
forth our views. We regret that, even the said information is not shared with us, the stake
holders, who are most concerned with the very topic. However, we deem it our bounden duty
to give our feedback, (though we were kept in darkness) keeping in view the service to 80000
pensioners.
We are now placing some important points about TPAs’ ACTION TURNING TO GRIEVANCE.
1. GIPSA PPN IS NOT APPLICABLE TO OUR MEDICLAIM POLICY. BUT TPAs PROCESS THE CLAIM AS
PER GIPSA PPN, RESULTING IN WRONG SETTLEMENTS.
2. TPAs provide GIPSA NON-MEDICAL LIST for Non-medical Items to their NETWORK HOSPITALS,
which is less favorable than our NON MEDICAL LIST, provided in ANNEXTURE II of master policy
conditions, resulting in recovery of excess amount under NON MEDICAL.
3. In case of Cashless Reimbursement in TPA's NETWORK HOSPITAL, prior approval is about 50%
of the claim amount. The hospital demands balance 50% from the insured. This defeats the very
object of CASHLESS TREATMENT FACILITY.
4. It is observed that TPAs’ MEDICAL TEAM is far less qualified than the treating doctor
(specialist or doctorate or highly qualified), and this results in the wrong settlement of claim. We
have come across several times that those doctors cannot even understand the nature of
disease and treatment. Many a times we talked to those doctors of TPA and arranged for
conference call with the treating doctors, for getting the claim settled.
5. The cost of all medicines prescribed at the time of discharge should be paid/reimbursed,
irrespective of the disease for which hospitalization was necessary.
6. For some patients, especially of cancer, each month claim would be preferred. Each month,
TPA asks for KYC documents. It should be stopped. Moreover, payment will be released by the
respective Divl office of LIC who have our KYC documents.
7. In many cases, settlement will be finalised deducting bills of medicines on the ground that
original bills not submitted. This harassment is experienced by many, though original bills were
submitted. After threatening by the claimant, TPAs made the payment.
8. Even when a cashless claim is passed, TPA asks for ID proof and e card for settlement of pre
and post hospitalisation claim, this is unwarranted, causes unnecessary delay. This is avoidable
and should be avoided.
9. Delay occurs from the TPA side for sanction of the remaining part of the bill in case of a
cashless claim. This causes a delay in discharge; this should be taken care of.
10. Claim of Family pensioners and super aged pensioners should be sympathetically
considered, delay to be avoided, unnecessary queries to be avoided; so as to avoid mental
harassment.
Sir, shortly discussions may start at your end with the New India Assurance company
Ltd/Insurers, for renewal of our MediClaim policy wef 01.04.2025. We vehemently appeal to you
to consider our above issues and discuss with the insurer/TPAs to achieve a zero grievance claim
settlement.
With thanks and regards,
Your Sincerely,
General Secretary
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