Sujit Banerjee (name changed), a retired senior citizen of 73 years, had approached the Moneylife Insurance Helpline of Moneylife Foundation seeking help with his rejected mediclaim on flimsy grounds by the TPA (third party administrator). The TPA alleged that the insured suffered from hypertension for 15 years without having any documentary support. The TPA even chose to ignore medical certificate of the illness from a doctor with super speciality degree in neurology. Inadequate medical expertise of the TPA staff has been reported by the media for a long time.

Taking the complaint to the grievance cell was the next step followed by the Moneylife Insurance Helpline in escalating the matter to the GM, grievance cell of New India Assurance. The claim was paid for Rs34,313, overturning the TPA s debatable decision.

The case proves that TPAs should not be settling claims, which is included in the new health insurance guidelines from IRDA (Insurance Regulatory and Development Authority). Insurance companies have much more expertise on medical intricacies than a TPA. The regulations put the onus on the insurer to give specific grounds of settlement and denial of claim. In short, the insurance company cannot play the blame game that the TPA is making decisions on the claims.

MD India (TPA) had repudiated Mr Banerjee s for a claim related to illness of reversible ischemia with neurological deficit, arguing that the Current illness is a complication of hypertension which is since 15 years as per indoor case papers . According to Mr Banerjee, I do not know from where the TPA got this information as neither the case papers nor the discharge card made any reference of 15 years history of hypertension. Somewhere a mention is made of mild hypertension which is natural as an age-related problem. I am a customer of New India Assurance for the last 20 years or so.

On receipt of the TPA repudiation letter, Mr Banerjee contacted Dr Neeta A Mehta, under whom he took treatment at Nanavati Hospital in Mumbai. She readily issued a certificate mentioned that the illness was more like Transient Ischemic Attack and further added that mild fluctuation of blood pressure is not the cause of this attack . Mr Banerjee says, Dr Neeta Mehta is an eminent neurologist of repute and besides being an MD also holds a super speciality degree of DM in Neurology. I wonder how the TPA can ignore the opinion coming from such an eminent doctor. Moneylife s contribution helped to get justice for Mr Banerjee.

Interestingly, at a January 2013 high court hearing of a public interest litigation (PIL) filed by Gaurang Damani, IRDA member (non-life) M Ramaprasad admitted that even veterinarians are appointed by the TPAs in addition to ayurvedics and homeopaths to assess claims. There have been cases where specialist doctors were not able to convince the need of specific procedure to TPA doctors, who may be well qualified in their respective field but not in the specialised allopathic stream.

Mr Banerjee also pointed out that all New India Assurance mediclaim policies showed no pre-existing diseases except for the policies for the years 2009-10 and 2010-11 which erroneously showed pre-existing hypertension and diabetes. Mr Banerjee thinks that it may be due to a clerical error inadvertently inserted and the loading was recovered. He had to protest for such a fallacy and the pre-existing illnesses were removed in the subsequent policies till today. It affirms what Moneylife suggests about the importance of checking your policy document so that there is no discrepancy in the product renewed or sold to you.

In case you have an insurance issue, please write to Moneylife Foundation.