Nishant (Test Analyst) 15 March 2012

Health insurence + post maternity

Myself and My wife are covered under Group health insurance policy of my company for Rs 100000/-. I had claimed for Maternity benefit which has a limit of 30000 which got passed by TPA. But after 8 days of delivery my wife got admitted again and diagnosed with 'PIH and Post delivery convulsion due to PRES". I made a second claim for this hospitalisation of 8 days costing me Rs. 84179/-. The claim has been rejected by TPA with below reason:

The patient was admitted with the complaints of PIH,Post delivery convulsion due to PRES .The ailment is a complication of maternity. As the Maternity limit is already exhausted, the present claim is not admissible under this policy. PIH,Post delivery convulsion due to PRES.

Can anyone please suggest me on this?

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3 Replies

Kumar Doab (FIN) 15 March 2012

Insurance is usually meant for unexpected risk, and pregnancy is not regarded as such a risk.

In your case the employer has provided "Group health insurance policy" implying the terms and conditions are negotiated and finalised by employer and insurance company. The policy is not Pregnancy health Insurance.

The details of what can be claimed and what can not be claimed are described in Master Policy which you can obtain from concerned personnel of HR.

Some companies provide Post Delivery Complications e.g. Star Health Insurance

(f). Post Delivery Complications Accruals within Hospitalization Limits

However there are conditions:

What cannot be claimed?

Expenses for delivery of a child within 36 months of continuous coverage from the date of commencement of this policy with the company. The waiting period of 36 months is reduced to 24 months when the policy is taken for a period of 4 years.

Consumer Forum may/may not agree with contentions of TPA. However you must check with a competent and experienced lawyer specialising in Consumer Cases.

Attached File : 143294881 post delivery complications.doc downloaded: 59 times

Nishant (Test Analyst) 16 March 2012

Thanks Mr kumar.

I agree with you that pregnancy is not regarded as such a unexpected risk. but the problem which occured after delivery was unexpected risk.

Can you please guide me for any lawyer and also suggest me the way if I can lodge complaint with consumer core and how?

Thank you very Much

Kumar Doab (FIN) 16 March 2012

If you wish to approach LCI lawyer you can perform “Lawyer Search" at LCI website. You can also click on “Related Civil Law Lawyers" on the bottom of this web page.

Your near and dear one can also guide you a competent and experienced lawyer specializing in Consumer Cases, at your location. You can also enquire about leading lawyers at local Consumer Forum and discuss your case and get the merits evaluated. Your lawyer may advice you to submit a written representation to the TPA, Insurance Company or may prefer to issue a legal notice.

The escalation steps are: BM/ZM in Local Office of Insurance Company ( even a Development/Admin Officer in this insurance company can guide you and give you useful inputs on how to proceed and merits in your case. Moreover they are to be made a party.), Highest authority in insurance company, HR-Head and HR personnel handling Group Health Insurance of your company who can provide you copy of policy document and may also take up with insurance company and you must submit your contentions in writing to your employer and Insurance Company and build record, IRDA and Insurance Ombudsman ( both usually go by terms and conditions of the policy and the TPA has contended as per terms of the policy you may not have chances to succeed), Consumer Forum. Consumer Forum can overrule contentions of TPA/Insurance Company.

Consumer Forum decisions can be seen online at CONFONET. You may find a relevant decision.

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Valuable advice of learned experts/members is sought.