Home | About Us | About TPA | Careers with Us | Our Clients | Feedback | Claim Guidelines | Contact Us
Our Services
Benefit Solutions
  • This has reference to our memo marked HO/Tech/A DT 21.5.07 clarifying doubts on the revised Medi claim policy. We have now received some more queries from some of the ROs and we clarify the same as below for your information, reference and circulation to all concerned.
  • Q. 1: In the revised Medi-claim Policy, a pre-existing disease becomes admissible after 4 claim free continuous policy years. Suppose A person Has An illness at the time of taking the policy, say hernia for example, and on the 5th policy period, he claims for hospitalization for a surgery to remove it. He has not claimed for hernia all 4 years but had a claim settled during the period of some other disease, say fever. Can we admit the claim for the present surgery (the disease was pre-existing) as his policies had been claim free for this disease?
  • REPLY : Yes, the claim for surgery for a pre-existing illness/ disease is admissible in the 5th year if the policy is claim free for the pre-existing disease for 4 years of continuous renewal. Claims made, if any during this 4 years period for other illnesses/diseases do not affect the claim of a pre-existing disease in the 5th year.
  • Q. 2: In the above case, suppose he has not claimed ever during the entire 4 years even for the other ailments and now in the 5th year claim for the hernia surgery. On investigation, we find that he had been hospitalized some time back for the same illness but had not lodged any claim with the Company (has borne all the expenses by himself). S0, if we go through all his 4 previous policies, they had been claim free. Can we settle the present claim?
  • REPLY : Yes. As Clarified in above, if the policy is claim free for the pre-existing disease during the 4 continuous renewals, the claim is admissible. The hospitalization and treatment of the policyholder for a pre-existing disease during the 4-year period and no claim made on Insurer entitles him for a claim for the pre-existing on the 5th year.
  • Q. 3: The minimum SI under the revised Mediclaim is Rs 50000/- One insured renews his previous policy of SI Rs 15,000/- now for Rs 50000/- As is obvious, he had no choice to continue the same amount of SI since the revised policy does not allow SI of Rs 15,000/-. During the previous period, he had contracted an illness, say cancer that may require treatment in the subsequent policy periods also. In the earlier days, we would have restricted the SI for this particular, illness to Rs 15000/- only. Now as the enhancement of sum was not according to his option, will we be able to restrict the claim amount of the existing illness to the previous sum insured?
  • REPLY : No, we cannot restrict the SI to previous SI, as there is no such restriction on the policy. Moreover the enhanced SI is an unilateral offering of the Insurer and the policy holder has no choice as to SI whatsoever. However, it may be noted that for diseases which are continuing or recurrent in nature and contracted under the previous policy with sum insured less than Rs 50,000/- in the revised policy it can only be refixed at Rs 50,000/- only to conform to minimum Sum insured prescribed under the revised policy.
  • Q. 4: Most of the health policies nowadays walve the Medical pre check up requirement if the proposer holds our Company’s health insurance policy for the last few years continuously. Can we consider Jan Arogya policy also in this case for waiving the condition?
  • REPLY : Yes as the cover under the Jana Arogya Policy is along the line of individual Medi claim Policy.
  • Q. 5: In Varishta policy, critical illness benefit is given once the insured survives the illness for 30days. If a person gets the full amount (Rs 2 lacs) for a particular illness, say cancer, but gets completely cured on treatment. He then renews the policy. In the next policy period, he contracts another critical illness and crosses the survival period. Can we pay the claim?
  • REPLY : Yes. However, in the renewed policy the claimed Critical illness may be specifically excluded.
  • Q. 6: Whether 10% discount is given for deletion of Domiciliary Hospitalization from group Mediclaim policy?
  • REPLY : The provision of Domiciliary Hospitalization has been withdrawn from the policy and hence allowance of discount for deletion of Domiciliary Hospitalization under Group Mediclaim policy does not rise.
  • Q. 7: The insured was covered under Mediclaim policy since 2001 and the Sum Insured was opted Rs 25,000/- + CB of Rs 5000/- The policy has been renewed for Rs 50,000/- under revised Mediclaim policy on 22.4.07. The insured underwent “Hysterectomy” on 09.5.07 and submitted her claim. Clarify whether the claim should be settled as per previous policy (SI Rs 25,000/- + Rs 5000/- CB) or according to the renewed policy (Rs 50,000/-) since there is a possibility that the disease might have contracted during the expired policy period.
  • REPLY : The policy appears to be claim free for past 4 policy periods and is renewed for a Sum Insured of Rs 50,000/- as per provisions of revised Mediclaim policy. The claim arising under the renewal policy, therefore, may be settled as per the revised Sum Insured Offered.
  • Q. 8: How the Treatment Of claims arising out of extra uterine pregnancy under the revised mediclaim be dealt with?
  • REPLY : As per exclusion 4.12 of the revised Mediclaim policy, treatment arising from or traceable to pregnancy, childbirth including Caesarian section, miscarriage, abortion or complications thereof including changes in chronic conditions arising out of pregnancy are not payable. However abdominal operation for extra-uterine/ ectopic/ tubular pregnancy cannot be equated to normal pregnancy for the former being an aberration endangering the woman’s life and the foetus not surviving the full term is payable on submission of Ultra sonographic Report and certified by Gynecologist that it is life-threatening one if left untreated.
  • Q. 9: Some well-known hospitals offer package rates for treatment of particular disease for example, a particular hospital has three packages for bye-pass surgery Rs 1,25,000 (if admitted and post operative treatment taken at General ward ) Rs 1,65,000 (if admitted and post operative treatment taken at private ward) How to settle claims when the payment was made by the claimant as per package rates when the revised Mediclaim has sub limits ?
  • REPLY :
      i) The revised Mediclaim has sub limits on various expenses and the insured must arrange to submit treatment bills on different heads to conform to policy provisions and to avail the benefits under the policy. In case the insured avails treatment under package scheme of hospital, the components of the package under the relevant heads may be asked for / ascertained from hospital and the claim may be settled applying sub limits.
      ii) Where despite reasonable efforts, the detailed break up is not available and the treatment has been taken under an advertised package of the hospital, the claim amount payable as per sub limits may be worked out on Sum Insured opted to arrive at the settlement. For example, in the above case, if the policy is for SI of Rs 2,00,000/- and the insured undergoes a Bye Pass Surgery Sum Insured – Rs 2,00,000/- Hospitalization period 10 days
      a)Room/Boarding & Nursing Expenses
      1% of SI per day (Overall 25% per illness) – Rs 2000*10 = Rs 20,000/- or Rs 25,000/- (Maximum)
      b) Doctors fees (25% of SI) - Rs 50,000/-
      c) Medicines etc (50% of SI) - Rs 1, 00,000/-
      So amount payable Rs 1, 70,000/- or Rs 1, 75,000/- (Max)
    In package 1 of Rs 1,25,000/- and Package 2 of Rs 1,65,000/- the amount payable is full and Package 3 of Rs 2,00,000/- the amount payable is Rs 1,70,000/- or Rs 1,75,000/- as applicable.
    1. iii) In case of Ad-hoc/ unadvertised packages, details under different heads may be obtained to settle the claim applying sub-limits.
  • Q. 10: TPAs are of view that policies are issued on or after 1.4.07 shall be treated as first policy and ever if the insured is holding a policy of NIC for 4 or more years before 1.4.07 shall not be entitled for coverage of pre-existing disease as per revised Mediclaim policy. Clarify
  • REPLY : Insureds holding Mediclaim policies for 4 years or more without break as on or after 1.4.07 may be entitled for coverage against pre-existing disease in view of the provisions of the revised Mediclaim policy.
  • Q. 11: As per condition No of the Group Mediclaim policy, maternity claims are payable for first two living children. A insured person covered under a Group Mediclaim policy preferred Mediclaim from first pregnancy when two living twins are born. The insured person has preferred 2nd maternity claim. Whether the claim is payable?
  • REPLY : The maternity benefits under the policy provides for two living children and not for two pregnancies. Hence, if already 2 living children are there. No further maternity benefit is payable.
  • Q. 12: The revised Mediclaim Policy states that the Pre-existing disease will be covered after 4-claim free policy period. What will be the fate of an insured who has been renewing his policy without any break for the last 4 years but in between there was a claim due to accidental injuries and not because of any disease. Will he be entitled to inclusion of pre-existing disease on renewal of the policy in the fifth year?
  • REPLY : Yes, the insured will be entitled to inclusion of pre-existing disease on renewal of the policy in the fifth year.
  • Q. 13: As regards the guidelines for identical SI for adult members and 50% for children. Many times, the clients are reluctant to have identical SI. Moreover, due to underwriting prudence, increases in SI of older insured’s are restricted, but due to the fresh guidelines the proposals are accepted without medical. How this unhealthy anomaly to be addressed?
  • REPLY : As per revised Mediclaim, SI of the primary insured and his dependants to remain identical with the exception of children who’s SI may be l9inked to 50% SI of primary member. The enhancement of SI without medical check up is allowed only in cases where the insured held a policy of NIC of 3 uninterrupted policy periods and hence the increase in SI is not automatic for older people. Further continuing or recurrent natures of diseases/ complications are excluded from the scope of cover of enhanced SI.
  • Q. 14: As per the fresh guidelines, in case of transfer of insurance from other Companies, no CB is continued. Whether other benefits like removal of first/ second year exclusion, 30 days exclusion etc can be allowed.
  • REPLY : The changes in the guidelines are being worked out and it will be circulated shortly.
  • Q. 1: As per policy condition 2.6, we are to approve the expenses of claimant limited to the charges applicable to entitled category. How are we to enforce this in case of re-imbursement claims where we are not having the tariff of hospitals?
  • REPLY : It is mandatory for TPA’s to collect the information from hospitals and see that the policy terms conditions are followed. Company cannot guide in this matter.
  • Q. 2: No payment shall be made under clause 2.3 other than part of hospitalization Bill. What is the action to be taken if the visiting consultants, surgeons, Anesthetist are providing the separate receipts?
  • REPLY : All the receipts submitted apart from final hospital bill as Consultant fees are to be deducted. In case of receipt of deduction reconsiderations, we need to ask for written clarification from hospital why the charges were not mentioned in original bill. And if we receive the modified final bill it has to be checked properly whether it is a proper bill with printed bill number and authentic. ONLY THAN THE MODIFIED BILL TO BE ACCEPTED.
  • Q. 3: What is the geographical demarcation of Mumbai with respect to treatment Zone 1, Zone 2, and Zone 3?
  • REPLY : All the regions coming under the BMC limits are to be considered under Zone 1. All other Regions including Thane come under Zone 3. TPA has to refer the Mumbai map and process accordingly.
  • Q. 4: Whether waiting period for pre-existing DM and Hypertension is applicable considering the current renewal as fresh policy or total coverage of insured with NIA has to be considered.
  • REPLY : Pre-existing Diabetes and Hypertension are to be covered only if the LOADING PREMIUM HAS BEEN PAID. COVERAGE IS CONSIDERED UNDER POLICY AND SETTLEMENT TO BE DONE AS PER THE SLABS MENTIONED IN POLICY. If Diabetes and Hypertension are pre-existing and loading premium has not been paid then it will be covered after four claim free years for these illnesses.
  • Q. 5: Whether waiting period of pre-existing illnesses is applicable considering the current renewal, as fresh policy or total coverage of insured with NIA has to be considered
  • REPLY : Total coverage of insured with new India is to be considered.
  • Q. 6: Pre-exiting illnesses are to be covered after four claim free years provided there has been No Hospitalization for this pre-existing illness in last four years. If we come across the Documentary evidence of hospitalization in last four years or if claim submitted by insured had been initially repudiated as pre-existing illness than what should be our stand. As claim is repudiated, the period becomes claim free but there has been hospitalization for that illness?
  • REPLY : Four-year period to be considered from date of discharge of hospitalization to give the benefit of Pre-existing coverage.
  • Q. 7: Whether waiting period as specified under policy clause 4.3 has to be applied considering the current renewal under revised policy as Fresh policy.
  • REPLY : It is applicable in cases of fresh policies if renewal with break or renewals from Insurance Companies.
  • Q. 8: In revised policies, Minimum Sum Insured is 1 lakh. If the insured had the Lower Sum, insured in previous year and the illness incepted in previous year what is the Sum Insured applicable for that current illness. Whether Room rent restrictions are to be applied as per the revised policy terms?
  • REPLY : The maximum limit of admissibility, for the illness will be the previous year sum insured, 4.1, 4.2, and 4.3, applicable for the enhanced Sum Insured. Room rent has to be approved as per the enhanced Sum Insured.
      Eg: Previous year Sum Insured: 25,000/-
      Current year SI: one lakh
      Illness: Pain in right knee since 6 months (in previous year) treatment in Current year
      Max Admissible Liability: 25,000
      Room rent to be approved @ 1000 per day
  • Q. 9: In cases where we are not getting the detail break up of package charges from the hospital in spite of repeated requests whether claims are to be settled as per any specific guidelines
  • REPLY : We need to approach hospitals and insist on giving break up. If not being submitted than we need to settle the claim on basis of entitled room category of insured as per the applicable Sum Insured.
  • Q. 10: If in case patient is admitted in some hospital which is not having the room category of applicable Sum Insured of Insured how is the settlement to be made.
  • REPLY : In such cases, the minimum room category has to be considered for settlement. Same will be in case where the packages are submitted.
      E.g.: SI 100000
      Applicable Room rent 1000 per day
      Hospital has minimum room rent as per 2000
      Room rent has to be settled as per 1000
      Rest of other charges to be settled as per the minimum room category of hospital
      Surgical package charges also to be settled as per the Minimum Room category package
  • Q. 11: In Janta Mediclaim policy we are having two different lists of capping regarding the surgery charges, DR visit charges Room Rents. Which one is to be followed?
  • REPLY : The list, which is reflecting the Rounded figures, has to be considered.
  • Q. 12: In Janta Mediclaim How, are the CGHS rate charges to be applied?
  • REPLY : CGHS RATE NEED NOT TO BE REFERRED AT ALL Only capping as specified in policy are to be followed.