Mediclaim Insurance - TPAs must be made accountable to Insured

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The Mediclaim policies offered by various insurance companies are administrative mustered through the TPAs.
These TPAs - licensed by IRDA - are supposed to help the administrative work insurance companies. They are supposed to act as support to Insurance companies. However more often than not, they act as independent decision makers while assessing claims. The expenses are arbitrarily disallowed with no explanation. What is worse that in such case, no reference is made to Insurance Company for guidance. When an aggrieved person approaches insurance company, one is bluntly told that TPA has rejected the claim. But TPA is a processing agent, they can't be the decision makers. This happens even where the treatment is taken in pre-approved hospitals. When a pre-approved hospital gives its estimate or bill for treatment, why should the TPA deduct any of the medical expenses incurred.
Its time IRDA took note of the highhandedness of these TPAs and makes it mandatory for insurance companies to review all cases where expenses are disallowed.
Similarlry, TPAs do not permit a category of expenses called Surcharge applied on the total value of the bill - even where total amount is within the policy limit. This is an undue load on patients as these surcharges are usually 15 to 20 percent of the bill amount. Funnily, of the bill gives a single amount inclusive of Surcharge, theseu are paid off. Is it not strange or illogical ? My wife has been hospitalised at one of he leading hospitals at Mumbai and I have been forced to pay 20 percent surcharge which was rejected by TPA and insurance comoany. This is abdiscretionary amount that insurance company can pay. But the issue was lobbed between insurance company and TPA with insurance company claiming amount rejected by TPA and hence can't be paid. So who has the primary contract - TPA or insurance company ?

And now my wife is expected to go through an organ transplant operation and Surcharge amount is over 5 Lakhs which will be rejected bybTPA and Insurance company.
I request IRDA to take note of such issues and help the hard pressed patients who incur a massive financial and emotional cost of treatment. If the insurance company does not honour its basic commitment under the policy, what good are these policies.



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