RBI RETIREES' MEDICAL ASSISTANCE FUND SCHEME (MAFS) - VIOLATIONS BY TPA.
PM
For Information:
While Bank retirees are facing difficulties on account of restrictive practices from United India Insurance Company,under Medi Claim Insurance Scheme,as against agreed terms of Employees Unions with IBA,RBI retirees too are facing problems on violations by the insurance co -IFFCO Tokio.
Pl Read :
have come to know from the retired members of MAFS that the present Insurance company -IFFCO Tokio- with whom the GMP contract for the period 2015/16 has been renewed- has initiated restrictive practices regarding settlement of their pre-authorisation bills with Network Hospitals. Some other unauthorised practices have also been observed in cases relating to planned hospitalisation such as, Cataract Surgery and other procedures where hospitalisation under a package are agreed to by the retiree members. In this connection, we emailed to central office members’ concern in the matter. Some extracts form the emailed letter are given below.
“Earlier where treatment of cataract surgery was planned, the TPA
(under United India Insurance co.) used to provide for the entire admissible amount in one instalment capped at RS 40000/- on submission of the required case papers by the hospital…”
“Our members who have undergone cataract surgery in the network hospitals have reported that the amount estimated by the hospitals is not being released by the TPA in one go as was being done by the same TPA under earlier Insurance company. In a recent case (details in Annexure I), where the TPA (Medi Assist, Noida) approved the pre estimated amount as conveyed to them in 3 instalments, that too 60% of the amount claimed by the hospital. The balance amount was sanctioned 5 hours after the surgery was performed. Till then the patient remained stuck in the hospital. He was thus forced to expose himself to the avoidable risk of aggravation/infection. It is well known in Health Care Industry that the cataract treatment is a fixed package where the cost of lens and surgery charges, as a rule, are pre-fixed, and there is little scope for any subsequent changes in the estimates.”
We have also reports and papers which prove that United India Insurance is a better rated company by the Health Care Industry and enjoys a higher credit limit than the present insurance company.Our members are also at a loss to understand the favour bestowed upon a Company in Private Sector and all love lost for Public sector Company owned by the nation, when generally the beneficiary employees were satisfied by the implementation of the policy by the Public sector Company since the inception of the scheme.
As per the guidelines issued by Insurance company to TPA, under the pretext of Package System, TPA has reduced the Cashless Facility and the Hospitalisation limit of the retirees to a farce . In fact, by disallowing the genuine claims of the retiree including that of medicines and investigation charges etc. the Insurance company is violating the provisions in the policy. Who has authorised the company to sanction the pre-authorisation amount on the basis of the room rent below the eligibility of the member concerned?
The difference in the amount between the eligible amount and actual paid amount for Room Rent/ICU/ICCU is also payable by Regional Office in accordance with the para.No.7 of C.O. CircularC.O.HRDD.No.G.100/4241/18.03.00/2010-11 dated November 1, 2010.
However, We have come across many cases where the members have not claimed the room rent difference from the Bank as they are not aware of the same. The instructions relating to retirees are not well circulated, although central office invariably advises regional offices to bring the contents of such circulars to the retirees’ associations. It is not being done as no retirees’ association is on the mailing list of the Bank. Instructions remain confined to a few in the Bank and the Medical Desk.
Or some times, the members who are coping with the prolonged sickness are required to approach bank at different times for settlement of the bills and trivial objections involved. Some consider it better to avoid the hassles in representing and then fearing for the negative response. They thank God for whatever amount is paid by the Insurance company. But this approach makes the Insurance company richer due to their grace rather than God’s.
In the circumstances, retiree members who have undergone hospitalisation may note to first obtain the full itemised details of rejections along with reasons /summary of the settlement from the TPA. TPA is bound to provide the same as per Regulatory Authority’s guidelines. Then they should represent each and every deduction /wrong settlement of their bills first to the TPA, and if rejected or not replied to within 3 weeks , to Central Office through their local office. We should also bring all such information about MAFS to the notice of retirees in Class IV and Class III who are already suffering due to very low room rent admissible to them.
/airbiopf.3rd Feb'16
Sastry TVPC
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