Company corporate policy claim denied
vijay waghmare
(Querist) 04 August 2014
This query is : Resolved
Dear sir,
my wife had baby 29.7.14 but after birth we came to know that baby have "Congenital External Disease" which i have admitted in the hospital & filled the cashless facility after some document verification by insurance company they have denied the claim after that i have followup with my HR but all are worthless can you pls guide me on that manner what process need to recover the amt from insurance.
employee limit-125000/- can be extend 175000/-
claim amount 118000/- now 200000/-
Vijay waghmare
ajay sethi
(Expert) 04 August 2014
you have not mentioned why insurance company has failed to pay claim amount ?
contact a local lawyer and based on his advice move consumer forum against insurance company for deficiency in service for refusal to pay claim amount upto insurance limit .
Kumar Doab
(Expert) 04 August 2014
You can act after receiving the denial of payment advice.This is usually supplied to all employees.
You should also obtain the policy T&C firmed up by corporate with insurance company in Master Policy, that is available with Medicliam Helpdesk/HR personnel or may be demanded from appointing authority, MD.
vijay waghmare
(Querist) 04 August 2014
thanks for supportive response here i am given the reason for denial of claim & has been given written through mail to my company HR. Pls suggest if even though we can move ahead.(statement is in inverted comma)
"Please refer the reply from Mediassist.
The case falls under “Congenital External Disease” which is not covered in the policy. I have personally spoken to Dr. Satish from Mediassist, who is handling the case. As per the papers received from the hospital during the cashless process, its points at the conclusion mentioned above.
However, when we have all the papers from the employee after the discharge, we can relook at the case and take the consultation of the third party doctor also. It does not guarantee the claim settlement, but we can certainly take the opinion. Regret to inform that the employee currently would have to reimburse the bills".
Vijay Waghmare
Kumar Doab
(Expert) 04 August 2014
>>>Basic of Group Insurance has been discussed in some threads, you may go thru these at;
http://www.lawyersclubindia.com/forum/Query-on-group-insurance-schemes-46270.asp#.UiTZkdKAqWM
http://www.lawyersclubindia.com/forum/Premium-deduction-from-employees-salary-65914.asp#.UiTY8tKAqWM
http://www.lawyersclubindia.com/forum/Deduction-of-premium-for-insurance-without-employees-consent-46155.asp#.UiTWo9KAqWM
As you would note that the features of the policy are negotiated by the employer, and Master Policy is with employer, and the Master Policy should be obtained.
The company might not have included Employee's Representatives in negotiations on the subject including 'Inclusion and Exclusion' criteria's.
You should also know if company has applied Co-Pay option, by employees.
In such case the features of the policy should have been circulated.
>>> If you are eligible for ESIC but have not been provided with it in that case you can stress upon the company to pay.
If ESIC is applicable company can not replace it with Group Mediclaim Policy.
>>> The Third party opinion would enter with another legal tangle to your case.
It shall give opportunity to HR to wash its hands.
Hence before it is done you may approach a lawyer handling such/insurance/consumer/medico legal cases and seek opinion.
If some Doctor practicing in 'Pediatric Cardiology' is known to you, seek advice.
>>> You may also appeal to good offices of Chairman of the company and he can sanction funds from his corpus/welfare funds etc.............
Rajendra K Goyal
(Expert) 04 August 2014
Go through the terms of insurance and if claim wronly rejected send notice through your lawyer and file consumer complaint.
vijay waghmare
(Querist) 05 August 2014
hi can anyone guide how i can get company's corporate master policy copy that i can check with the lawyer who is looking after these types of cases or anyone knows pls suggest that i can take follow up.
Guest
(Expert) 05 August 2014
Normally, employees become target of cheating if the health insurance is got done by the employers through middlemen non-insurance companies, instead of insurance directly from the medical insurance companies.
However, it is not the corporate policy of your company, which you need to check. It is the terms of the insurance policy, which are given on the back of each insurance policy with mention of diseases not covered by the policy. You may better ask for the copy of the insurance policy from your company or from the MediAssist company, which you have the right to obtain as a part of group insurance member.
Further, if you show the insurance policy to the doctor, he cannot help you to get past insurance claim, but can only guide you in which way the "Congenital External Disease" could have been made the part of treatment process to ensure insurance claim easily. However, for future guidance, you can get advice of the doctor on receipt of copy of the insurance policy.
Kumar Doab
(Expert) 05 August 2014
M/s MediAssist is TPA.
Apparently the arrangement is that policy shall be administered thru TPA.
The Company that is your employer, Insurance Company, TPA are in possession of the Master Policy.
You can write to anyone and obtain copy of the policy showing Inclusion/Exclusion criteria, T&C etc.
T. Kalaiselvan, Advocate
(Expert) 07 August 2014
I fully agree with the opinions and suggestions of expert Mr. Kumar Doab on the subject issue. The undermentioned opino of the expert will only happen if you still keep waiting for the company's reply :
"The Third party opinion would enter with another legal tangle to your case.
It shall give opportunity to HR to wash its hands."
This is a vital issue which will be the result of the company to your insurance claim. Better initiate legal action before getting any reply from company, if you are eligible for claim as per insurance policy conditions.
vijay waghmare
(Querist) 08 August 2014
thanks mr Kumar & kalaiselvan, now i how much cost will be bear for legal action if the case is to be fill on court, recently i have much expenses on my baby's treatment,i request you to can have anyone advocate in pune that will support to me.
Kumar Doab
(Expert) 08 August 2014
If you wish to approach a Lawyer thru LCI databank you can conduct search at:
http://www.lawyersclubindia.com/lawyers_search/#.U-SykeOSwb8
Your near and dear ones can also guide you to a competent lawyer.
You can find out on your own from local consumer forum............
A lawyer in your neighborhood and known to you can also guide you.
Usually the fee is reasonable and it can vary from lawyer to lawyer.
You shall have to settle the fee/T&C etc on your own.
ajay sethi
(Expert) 08 August 2014
search in LCI database for lawyers in Pune
