GROUP INSURANCE AND DOMICILIARY CLAIMS

[rajasekaran rajamani]

Dear Friends,

On 27th October 2016 all the banks recovered Rs.20,010 towards premium for group mediclaim policy for retirees.

But till date they have not taken any step to upload the policy to know the contents, though we broadly know that

our coverage is Rs. 4 laca and 40,000 out of that is earmarked for domiciliary claim.

Neither the UIIC nor the banks are bothered about the retirees except promptly recovering the premium.

none had questioned them about this.

We should ask them to do that.Also the TPAs are not customer friendly when  every one expect the bank employee

to be so

I appeal to our leaders to urge upon the Banks and UIIC to upload the policy and also issue unambiguous guidelines for various claims in the background of new policy for this year.

Regards,

R.RAJASEKARAN

[S.R. CHOWDHRY]

This is very unfortunate. Why Insurance company is not forwarding names to TPA after receiving the premium from retirees? The claims are being kept pending and TPA is not responding properly. What bank unions are doing about this?

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[VENKAT BHATTACHAR]

Inspite of various emails, UIICO is least bothered to send me a copy of insurance policy through email.

Please guide me to obtain soft copy of the Policy for our personal reference.

Venkatabhattachar 

Retired officer from IOB

Mysore

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On Fri, 6 Jan, 2017 at 13:24, S.R. CHOWDHRY

<adv...@gmail.com> wrote:

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[PM]

                                   Please visit your Bank's website for details on Scheme as well as on TPA and other guidelines on submission of claims etc in detail:

https://www.iob.in/new_med_ins_sch_iobretirees.aspx

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[VENKAT BHATTACHAR]

Sir, 

Regarding our bank's website,  I know the full 

DETAILS.

Only I wanted a soft COPY OF THE POLICY of UIICO. for which the insurance company is not responding.

Sent from Yahoo Mail on Android

On Sat, 7 Jan, 2017 at 13:05, PM

<moha...@gmail.com> wrote:

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[Nita Sheth]

Sir I have also opted for domiciliary treatment.I have submitted claim for myself and my husband for the month of Nov'16.But today when I inquired about my claim with MD-India about my claim,they informed me that my name is not appearing in the retirees list.Iam retiree employee of Bank of Maharashtra.

Where is the lacuna and on whose part.We retiree s r helpless .

Whoever is it look into the matter .

[Prasanna K Nanda]

Dear Friend,

The group insurance policy is not in individual  names of retires covered. This is in in the name of IBA/ and individual Banks. Only guidelines with regard to operative parts ,

Network hospitals, claim procedure. various forms are informed to those who join the 

Mediclaim by  respective Banks. The Master policy may be with individual Banks and may be with Associations.

Therefore UIICO is perhaps not obliged to forward original Policy document to us as in case of individual Mediclaim.

P K Nanda,

UBI VRS, Bhubaneswar.

Sent from my iPad

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[Vij Parveen]

 हैल्लो बैंकर मित्रो,

         नमस्कार, 

            सबसे पहले सबको मेरी तरफ से सभी को नव वर्ष 2017 की बहुत बहुत बधाई 1 मैं  UIIC के बारे मेंआपको बतलाना चाहता हूँ कि मैंने Heritage Health Tpa को एक Domicialary bill 23 नवम्बर 2016 को रजिस्टर्ड डाक से भेजा था , जिसकी acknowledgement उन्होंने आज तक नहीं दी 1 

           पहली बात यह कि पहले तो जब हम online card status देखते हैं तो वहां पर card expired दिखाई देता है 1  अगर हम कस्टमर केयर पर बात करना चाहें तो पहले Heritage TPA के कस्टमर केयर का टोल फ्री नंबर ही नहीं मिलता  1 अगर गलती से मिल भी जाये तो जवाब मिलता है कि अभी आपके bill की कंप्यूटर में entry नहीं हुई है 1 मुझे समझ में नहीं आता कि आज 45 दिन बीतने पर अगर आज तक मेरी डाक ही कंप्यूटर मैं नहीं चढ़ी, तो उसके Reimbursement के लिए यह कितना समय लगायेगे 1 बैंक ने तो हमारी पेंशन मिलने की तारीख की भी इंतज़ार नहीं की और 26 october को ही 20010/- रूपये काट लिए !

           अब न तो बैंक का हेड ऑफिस मेल का जवाब देता है और न ही TPA कंपनी 1 Grievances में शिकायत का भी कोई जवाब नहीं 1 मुझे समझ नहीं आता कि जाएँ तो जाएँ कहाँ ?????????????

आपका साथी 

प्रवीन विज

Ex-UCO BANK

चंडीगढ़

07th January, 2017.

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[S.R. CHOWDHRY]

I have also submitted my claim for domicilary treatment. But receiving the same reply. I also contacted nodal officer of Uco Bank both at Head Office and Zonal office but they also did not provide any help.

[Anil Verma]

Dear friends to day I have seen following message being circulating among Whatsapp groups, hence being copied here for information :-

Mediclaim :

New guidelines of Health Insurance claims

*Rules and guidelines :

IRDA came out with *Health Insurance Regulations, 2016* for the entire medical insurance (mediclaim) industry. These regulations should benefit the over 20 crore citizens, who own a medical insurance (private and state) policy in India.

 

Main features of the Health Insurance Regulations (HIR), 2016

Related to Claims:

 

• *TPA is not permitted to settle/ reject/ repudiate claims*, as per Sec 33(c) of HIR 2016

• The claims settlement (rejection) letter should mention the specific *grounds for denial/ rejection of claim*, as per Sec 33(d)(iv) of HIR 2016

• Consumer will *get interest of 2% over the prevailing bank rates, on claims payment delayed beyond 30 days* and will have to mentioned in the policy document, as per Sec 28(iv) of HIR 2016

• The *claims payment* will be made from the Insurer’s bank account and *not the TPA’s*, as per Sec 32 of HIR 2016 Earlier claim cheques were issued to the customer by the TPA (Third party Administrator), but now the insurance company would have to write a claim cheque or ECS directly to the customer. This would eliminate the float that some of the TPAs were enjoying. Also, there was never any public audit of the claims funds sanctioned by the Insurance company v/s actual amount disbursed by the TPA.

• TPA has to electronically transfer the claims document to Insurer for a decision as per Sec 35(a) of HIR 2016

• The TPA will ask for claims related *papers in one time only*, and not in a piece meal manner as per Sec 27(ii) of HIR 2016

• Non-allopathic (AYUSH) treatments may be covered, as per Sec 18 of HIR 2016

• Fees to the TPA shall not be related to reduction of claims costs as per Sec 20(6) of Health Services Regulations for TPA, 2016

• Discounts offered by hospitals have to passed on to the policyholders, as per Sec 20(9) of Health Services Regulations for TPA, 2016

• Change of TPA will be intimated to the consumer in writing 30 days before hand as per Sec 34(a) of HIR 2016

 

Related to policy document:

• Premium for individual policies cannot be increased at renewals in an arbitrary way, especially after a claim is made, as per Sec 25(i) of HIR 2016.

• There will be no change in premiums in individual policies *for 3 years* after initial offering, as per Sec 10(c) of HIR 2016

• Cannot force consumer to shift to other product as per Sec 11(c) and 17 of HIR 2016

• All policies will be ordinarily renewable as per Sec 13 of HIR 2016

• Customer Information Sheet must be part of the policy document, as per sec 26 of HIR, 2016

• *ID card to have logo of Insurance company (not of TPA)* and the card may be permanent, as per Sec 30(f) of HIR 2016

• Policy is portable from one Insurer to another, 45 days prior to maturity of policy (including cumulative bonus would also be portable), as per Schedule I, Sec(1) & (18) of HIR 2016

• Free-look period is 15 days as per Sec 14 of HIR 2016

• Cumulative bonus amount to be clearly mentioned in the policy, as per sec 16(i) of HIR, 2016

• All disclosures as per the new regulations have to be included in the policy document, as per sec 28 of HIR, 2016

• For multiple policies, claims under other policy can be made after exhaustion of Sum Insured in the earlier policy, as per Sec 24 (ii)2 of HIR 2016. The option to chose will remain with the insured

 

Related to Senior citizens:

• Entry age is *up to 65 years* and there will not be any exit date for a policy as per Sec 12 of HIR 2016

• Premiums shall be fair, justified, transparent and duly disclosed upfront, as per Sec 23(i) of HIR 2016

• Separate claims & grievance cell, as per Sec 23(ii) of HIR 2016

 

Other regulations:

• Withdrawal of a product needs prior IRDA approval and atleast 3 months notice, as per Sec 5(ii) of HIR 2016

• Group Insurance cannot be offered to groups specifically formed to avail insurance, as per Sec 7(a) of HIR 2016

• Pre-insurance check-up cost included in premium as per Sec 15(i) of HIR 2016

 

Important precautions to be taken in case of claims:

• Best option for the consumer is to obtain Cashless facility i.e. the Insurance company pays the bills directly to the hospital. But the hospital must be part of their preferred network (PPN), which list should be available on the insurance company website.

• If you wish to take treatment in a hospital, which is not on the PPN cashless list, then make sure you intimate the Insurance company/ TPA within 24 hours of admission in any hospital.

• In case of a pre-planned surgery, it is better to inform the Insurance company/ TPA much earlier.

• As per IRDA’s guidelines to the Insurance companies, *the consumer cannot be forced to sign the discharge or Settlement Intimation voucher*. Signing the discharge voucher does not mean that the Insurer’s liability is over.

 

Disputes resolution, especially Claims processing

 

For claims-related complaints, consumers can write to the Grievance cell of the Insurance company. As per IRDA guidelines, grievances must be acknowledged by the Insurance company in 3 working days and it must be *resolved in 15 working days*. If there is no response to the letter, you can file a Right to Information (RTI) application with the Grievance Officer.

The *IRDA Call Centre (toll-free at 155255*) also offers an alternative channel for policyholders, serving from 8 AM to 8 PM, Monday to Saturday in Hindi, English and various Indian languages.

You can also write to *compl...@irda.gov.in* or online or through post at:

Consumer Affairs Department

Insurance Regulatory and Development Authority (IRDA)

3rd floor, Parishram Bhavan,

Basheer Bagh, Hyderabad

For still unresolved disputes of *less than Rs 20 lakhs* pertaining to claims settlement or regarding premiums paid/ payable and non-issue of insurance documents, the *Insurance Ombudsman* can be approached. The written complaint with the relevant claim papers can be send by the customer himself (*no lawyer is required*), within 1 year of dispute. After registering with the Ombudsman office, attach this application document.

Contact details of Insurance Ombudsmen in India

*Contact Details*

Jurisdiction

MUMBAI

Office of the Insurance Ombudsman,

3rd Floor, Jeevan Seva Annexe,

S. V. Road, Santacruz (W),

Mumbai – 400 054.

Tel.:- 022-26106928/360/889

Fax:- 022-26106052

Email:- *ombudsm...@gmail.com* or

ombu...@vsnl.net

States of Maharashtra and Goa.

AHMEDABAD

Office of the Insurance Ombudsman,

2nd floor, Ambica House,

Near C.U. Shah College,

5, Navyug Colony, Ashram Road,

Ahmedabad – 380 014

Tel.:- 079-27546150/139

Fax:- 079-27546142

Email:- inso...@rediffmail.com

State of Gujarat and Union Territories of Dadra & Nagar Haveli and Daman and Diu.

BHOPAL

Office of the Insurance Ombudsman,

Janak Vihar Complex,

2nd Floor, 6, Malviya Nagar,

Opp.Airtel,

Bhopal – 462 011.

Tel.:- 0755-2769200/201/202

Fax:- 0755-2769203

Email:- bimalokpalbhopal@airtelbroadband.in

States of Madhya Pradesh and Chattisgarh.

BHUBANESHWAR

Office of the Insurance Ombudsman,

62, Forest park,

Bhubneshwar – 751 009.

Tel.:- 0674-2535220/3798/1607

Fax:- 0674-2531607

Email:- ioo...@dataone.in

State of Orissa.

CHANDIGARH

Office of the Insurance Ombudsman,

S.C.O. No. 101, 102 & 103, 2nd

Floor,

Batra Building, Sector 17 – D,

Chandigarh – 160 017.

Tel.:- 0172-2706196/5861/6468

Fax:- 0172-2708274                    

Email:- omb...@yahoo.co.in

States of Punjab, Haryana, Himachal Pradesh, Jammu & Kashmir and Union territory of Chandigarh.

CHENNAI

Office of the Insurance Ombudsman,

Fatima Akhtar Court,

4th Floor, 453 (old 312), Anna Salai,

Teynampet,

CHENNAI – 600 018.

Tel.:- 044-24333678/664/668

Fax:- 044-24333664

Email:- inso...@md4.vsnl.net.in

State of Tamil Nadu and Union Territories – Pondicherry Town and Karaikal (which are part of Union Territory of Pondicherry).

DELHI

Office of the Insurance Ombudsman,

2/2 A, Universal Insurance Building,

Asaf Ali Road,

New Delhi – 110 002.

Tel.:- 011-23239611/7539/7532

Fax:- 011-23230858

Email:- iobd...@rediffmail.com

States of Delhi and Rajasthan.

GUWAHATI

Office of the Insurance Ombudsman,

‘Jeevan Nivesh’, 5th Floor,

Nr. Panbazar over bridge, S.S. Road,

Guwahati – 781001(ASSAM).

Tel.:- 0361-

2132204/2131307/2132205

Fax:- 0361-2732937

Email:- ombuds...@rediffmail.com

States of Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland and Tripura.

HYDERABAD

Office of the Insurance Ombudsman,

6-2-46, 1st floor, “Moin Court”

Lane Opp. Saleem Function Palace,

A. C. Guards, Lakdi-Ka-Pool,

Hyderabad – 500 004.

Tel.:- 040-23325325/23312122

Fax:- 040-23376599

Email:- insom...@gmail.com

States of Andhra Pradesh, Karnataka and Union Territory of Yanam – a part of the Union Territory

of Pondicherry.

KOCHI

Office of the Insurance Ombudsman,

2nd Floor, CC 27 / 2603, Pulinat Bldg.,

Opp. Cochin Shipyard, M. G. Road,

Ernakulam – 682 015.

Tel.:- 0484-2358734/759/9338

Fax:- 0484-2359336

Email:- iok...@asianetindia.com

State of Kerala and Union Territory of (a) Lakshadweep (b) Mahe-a part of Union Territory of Pondicherry.

 

KOLKATA

Office of the Insurance Ombudsman,

North British Bldg., 3rd Floor,

29, N. S. Road,

Kolkata – 700 001.

Tel.:- 033-22134869/67/66

Fax:- 033-22134868

Email:- iom...@vsnl.net

States of West Bengal, Bihar, Sikkim, Jharkhand and Union Territories of Andaman and Nicobar Islands.

LUCKNOW

Office of the Insurance Ombudsman,

6th Floor, Jeevan Bhawan,

Phase-II, Nawal Kishore Road,

Hazratganj,

Lucknow-226 001.

Tel.:- 0522-2201188/31330/1

Fax:- 0522-2231310.

Email:- iob...@sancharnet.in

States of Uttar Pradesh and Uttaranchal.

 

Other general guidelines:

• Generally *Family floater policy* is cheaper than buying individual policies for family members.

• Generally *bed charges are 1-2%* of the sum assured, depending on your Insurance carrier. All other charges like doctor visit etc. are often related to this bed charge, so it is important to be within these limits.

• Co-Pay means that a certain percentage or a certain fixed amount of the claim has to be borne by the policyholder. If co-pay is 15%, then whatever is the hospital bill you will have to pay the 15% and balance 85% only will be paid by the Insurance company.

• Generally *exclusions and pre-existing diseases* are not covered by a medical insurance policy (as specified in their policy document). Generally these *could be covered after 2 years of holding the policy*. Consumer must be honest in disclosing pre-existing ailments, if any.

• Policy can be *renewed within 15 days grace period* after expiry of the policy. However coverage is not available for the days for which the premium was not received by the Insurance company.

• One can transfer the policy from one Insurance company to another and the credits (including cumulative bonus) would also be portable.

• New policy should be issued within 15 days of submission of proposal

• To keep a check that people don’t try to take a policy where they have been diagnosed with some illness and they require immediate hospitalization, a *30 day waiting period* is kept, where Insurance Company will not pay any kind of claim within the first 30 days of taking the new policy, (*exception is that if policyholder meets an accident* then the claim is payable).

• Under Section 80D, *annual deductions* upto Rs 25,000 can be availed of (Rs 30,000 for senior citizens)

On 9 Jan 2017 09:48, "S.R. CHOWDHRY" <adv...@gmail.com> wrote:

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I have also submitted my claim for domicilary treatment. But receiving the same reply. I also contacted nodal officer of Uco Bank both at Head Office and Zonal office but they also did not provide any help.

On Sat, Jan 7, 2017 at 5:43 PM, Nita Sheth <nshe...@gmail.com> wrote:

[Anil Verma]

IRDA had issued revised guidelines on the health insurance in July 2016, PDF file is enclosed for information. 

[Anantharaman Tg]

Thanks a lot, Shri Anil Verma ji for the useful health insurance guidelines.

Anantharaman

[Satyanarayana Rao]

Very useful message.Thanks for your information.

Sent from Yahoo Mail on Android

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[Kishore Kumar Nanda]

There is no mechanism for redressal of grievances.

Sent from Yahoo Mail on Android

[bhaskara sarma]

THERE IS NO TRANSPARENCY IN THE FUNCTIONING OF UIIC.THIS LEADS TO MANY INJUSTICES AND MALPRACTICES.I LODGED A CLAIM IN JULY 2016.SO FAR NEITHER SANCTIONED NOR REJECTED IN WRITING.

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[Anil Verma]

BHASKARA SHARMA Sir, with the help and guidence of each other we should all stand for this injustice and take the matter to some conclusive end. You should take up the matter with respective ombudsman for settlement of your claim you can get the claim settled along with interest. We have to fight of our own nither bank nor IBA will come to our support. I am enclosing revised guidelines for 2016 from IRDA for your information please read them carefully and prepare your case accordingly. I am sure result will be there. 

On 14 Jan 2017 09:42, "bhaskara sarma" <pbsa...@gmail.com> wrote:

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THERE IS NO TRANSPARENCY IN THE FUNCTIONING OF UIIC.THIS LEADS TO MANY INJUSTICES AND MALPRACTICES.I LODGED A CLAIM IN JULY 2016.SO FAR NEITHER SANCTIONED NOR REJECTED IN WRITING.

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[bhaskara sarma]

Dear Anil Jain,

Our sickness becomes more than doubled by follow up with UIIco.Anyway let us try.

With regards,

P B Sarma.

On Saturday, January 14, 2017, Anil Verma <anilver...@gmail.com> wrote:

BHASKARA SHARMA Sir, with the help and guidence of each other we should all stand for this injustice and take the matter to some conclusive end. You should take up the matter with respective ombudsman for settlement of your claim you can get the claim settled along with interest. We have to fight of our own nither bank nor IBA will come to our support. I am enclosing revised guidelines for 2016 from IRDA for your information please read them carefully and prepare your case accordingly. I am sure result will be there. 

On 14 Jan 2017 09:42, "bhaskara sarma" <pbsa...@gmail.com> wrote:

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THERE IS NO TRANSPARENCY IN THE FUNCTIONING OF UIIC.THIS LEADS TO MANY INJUSTICES AND MALPRACTICES.I LODGED A CLAIM IN JULY 2016.SO FAR NEITHER SANCTIONED NOR REJECTED IN WRITING.

[Anil Verma]

I am enclosing two screen shot from revised guidelines by IRDA FOR INFORMATION 

Which states that claims can be sent electronically for settlement to insurer or TPA. This may save us  (pensioners )from harassment which we are facing regarding acknowledgement and settlement. I will be sending my claim electronically in a day or so let us see what is response from TPA .

On 17 Jan 2017 09:24, "bhaskara sarma" <pbsa...@gmail.com> wrote:

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Dear Anil Jain,

Our sickness becomes more than doubled by follow up with UIIco.Anyway let us try.

With regards,

P B Sarma.

On Saturday, January 14, 2017, Anil Verma <anilver...@gmail.com> wrote:

BHASKARA SHARMA Sir, with the help and guidence of each other we should all stand for this injustice and take the matter to some conclusive end. You should take up the matter with respective ombudsman for settlement of your claim you can get the claim settled along with interest. We have to fight of our own nither bank nor IBA will come to our support. I am enclosing revised guidelines for 2016 from IRDA for your information please read them carefully and prepare your case accordingly. I am sure result will be there. 

On 14 Jan 2017 09:42, "bhaskara sarma" <pbsa...@gmail.com> wrote:

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THERE IS NO TRANSPARENCY IN THE FUNCTIONING OF UIIC.THIS LEADS TO MANY INJUSTICES AND MALPRACTICES.I LODGED A CLAIM IN JULY 2016.SO FAR NEITHER SANCTIONED NOR REJECTED IN WRITING.

[Anil Verma]

Dear friends, on 21st Jan 17 I also have sent mediclaim reimbursement in respect of my wife through electronic mode taking in to account the revised guidelines of IRDA  (I. e. Scaned copies of all documents sent by email to Ucobank....@bajoria.in ) inspite of repeated reminders to concerned quarters i. e. Heritage office Kolkata, help desk ucobank PAD at H.O.,Mr Prasungosh nodel officer from heritage tpa assigned to Ucobank, Mr.Argit shah attending to claims and providing necessary advice on claims at h.o., grevances cells of UIICO & HERITAGE but none of them have replied to my quires or acknowledged my mails. Or Whatsapp massages . Their telephone nos remain engaged and there is no response. 

As regards Cashless treatment at hospital the TPA cell in hospital informed me that permission has to be routed through them, till confirmation comes from concerned TPA patient will not be admitted in the hospital. & for discharge after completing the signing of papers again till confermation is received patient will not be discharged from the hospital. Such permission usually takes 4 to 5 hours. And only hospitalisation will be covered and for pre and post hospitalisation we have to claim reimbursement. Thus patient has to overstay in hospital There by increasing the cost of stay and harresment to patient and attendent. For every admission same process has to be repeated. For one time admission cash less may be convenient but in weakly or emergency admissions it is not suitable. 

no transparent system how much hospital will claim and what will TPA reimburse is not known as hospital gives estimate on MRP of medicines, like wise any rebate given to patient by hospital or TPA to hospital ,is passed on to patient or not ,cannot be known. 

Since there is no responsibility being taken by anybody in processing the claim and acknowledging the documents what process should be followed in the matter. 

If the original documents are handed over to TPA through Z.O. Shimla under acknowledgement from TPA REPRESENTATIVE going to serve any purpose, 

Since ultimately we have to deal with TPA to get the claim settled. 

Can anybody suggest some other way to get rid of this situation? 

On 8 Jan 2017 09:23, "Vij Parveen" <vijpa...@gmail.com> wrote:

 हैल्लो बैंकर मित्रो,

         नमस्कार, 

            सबसे पहले सबको मेरी तरफ से सभी को नव वर्ष 2017 की बहुत बहुत बधाई 1 मैं  UIIC के बारे मेंआपको बतलाना चाहता हूँ कि मैंने Heritage Health Tpa को एक Domicialary bill 23 नवम्बर 2016 को रजिस्टर्ड डाक से भेजा था , जिसकी acknowledgement उन्होंने आज तक नहीं दी 1 

           पहली बात यह कि पहले तो जब हम online card status देखते हैं तो वहां पर card expired दिखाई देता है 1  अगर हम कस्टमर केयर पर बात करना चाहें तो पहले Heritage TPA के कस्टमर केयर का टोल फ्री नंबर ही नहीं मिलता  1 अगर गलती से मिल भी जाये तो जवाब मिलता है कि अभी आपके bill की कंप्यूटर में entry नहीं हुई है 1 मुझे समझ में नहीं आता कि आज 45 दिन बीतने पर अगर आज तक मेरी डाक ही कंप्यूटर मैं नहीं चढ़ी, तो उसके Reimbursement के लिए यह कितना समय लगायेगे 1 बैंक ने तो हमारी पेंशन मिलने की तारीख की भी इंतज़ार नहीं की और 26 october को ही 20010/- रूपये काट लिए !

           अब न तो बैंक का हेड ऑफिस मेल का जवाब देता है और न ही TPA कंपनी 1 Grievances में शिकायत का भी कोई जवाब नहीं 1 मुझे समझ नहीं आता कि जाएँ तो जाएँ कहाँ ?????????????

आपका साथी 

प्रवीन विज

Ex-UCO BANK

चंडीगढ़

07th January, 2017.