BHP Mediklemz

07/10/2024

https://acrobat.adobe.com/id/urn:aaid:sc:AP:00835afd-9d15-4571-9ae9-1ea77d2169cc

14/07/2020

Sharing a pleasant experience relating to a cashless claim under UIIC IBA-Bank of Baroda Health Insurance Policy for retired officers.

One of my retired colleagues was required to undergo urgent surgery for malignant benign prostate. The surgery was done at a very reputed kidney hospital in Nadiad. The total expenditure came to Rs. 7+ lacs. The TPA, after all verification cleared the claim for approx Rs.5 lacs. My colleague had to deposit around Rs.2.50 lacs as deposit with the hospital towards expenses which were not reimbursed by the TPA.

When he was called for post operative examination after 3 months, he was directed to accounts section. There he was advised that in response to the representation made by the hospital, the insurance company had agreed to reimburse the additional cost involved on account of use of latest robotics technique deployed by the hospital in his case. As a result, the hospital got almost all charges reimbursed from the insurance company and they refunded an amount of Rs.2.39 lacs which was taken as deposit from my colleague.

This was a surprise from the insurance company and the TPA that they reimbursed full cost to hospital without the insured filing any appeal or grievance in the matter.

03/03/2020

One of my retired friend from Bank of Baroda had to undergo bypass surgery for his heart. He availed cashless hospitalisation facility in one of the local network hospital in Vadodara. There were some complications during the surgery as a result of which he had to spend 21 days in hospital - a major time in ICU. The hospital submitted required papers to TPA with the total bill for Rs.5.00 lakhs. Sanction was received within 2 hours under base+super top up policy, with TPA deducting Rs.4 thousand from pharmacy bill towards non-medical items like gloves, etc.

The above experience shows that if hospital submits all papers and claim in proper format, generally the approval is given by TPA in reasonable time.

Thank you Mediassist Insurance TPA (Medibuddy) for prompt action.

08/10/2019

Messageg from Com SBC Karunakaran; explaining the other side of insurance plan offered by K N Faster and Co.

A letter purportedly from Insurance broker K.M. Dastur Reinsurance Brokers Private Limited is in circulation in social media which offers competitive rates for basic group insurance scheme to cover bank retirees. This letter requires interested retirees to send applications to M/s Dastur along with draft in the name of AIBRF A/c New India Assurance Co. Ltd. The sum and substance of this letter is the bank retirees have to come out of IBA scheme and rely totally on broker sponsored scheme.
As working president of AIBPARC, I am requesting our organization AIBPARC not to be associated with any such privately arranged scheme outside the purview of IBA scheme, a product government directive and bipartite settlement. ARISE advises its members to stick to IBA scheme as it has scope for reliefin the long run because of involvement of collective bargaining. I give my views of the Dastur sponsored insurance scheme which appears to have been negotiated by AIBRF without taking CBPRO or its constituents into confidence.
1) It is understood that IBA invited bids for group insurance scheme from more than a score of insurance companies including the four public sector insurance companies that included the above said New India Assurance Co. Ltd.
2) The best bid among them was reportedly found to be only that of United India Insurance Co. Ltd. though the premium was higher than last year’s. There are only two possibilities for not selecting New India Assurance Co. Ltd. Either New India Assurance Co. Ltd, did not participate in the bid finding the scheme as not remunerative or it quoted higher than that UIIC. If so, how the broker made the same New India Assurance Co. Ltd., offer lower rates now. Something is surely hidden in the fine prints. These rates for the current year may otherwise be enticing rates to entrap the retirees with an idea to hike the premia in the coming years. Please note that the same M/s Dastur was the broker for the IBA scheme and they did not intervene to keep the premium low.
3) The retirees who leave IBA scheme will not be able to join it later if they find the premium of New India Assurance Co. Ltd., prohibitively high in the future.
4) IBA devised the scheme only because of government guideline to formulate and fund group medical insurance scheme for both serving employees and retirees. IBA has half fulfilled the government guideline by having a group insurance scheme for retirees but failed to fund it for retirees. Though we are still not successful, the government guidelines to IBA leaves scope for the retiree organizations to bring pressure on IBA to abide fully by government guidelines as was done for serving employees. Any decision to leave IBA scheme is more likely to weaken the retiree organizations’ bid to get reliefs in medical insurance. Rejoining the IBA scheme later may prove to be impossible. So any member leaving the IBA scheme now tempted by the above offer of M/s Dastur may well remember the troubled history of second option for pension.
5) Retirees joining the above scheme may be detrimental to the interest of retirees because the scheme being privately negotiated at the back of UFBU, Government and IBA embarrasses the UFBU whose good will we require for most of our issues and gives a pretext to IBA and the Government to wash their hands off in the matter of reliefs like subsidizing the scheme. Retiree organizations may not be successful thus far in getting the present IBA scheme funded but they can exert moral pressure on both government and IBA because of the moral and legal claim on IBA for compliance with government guideline of framing and as well funding the group insurance scheme for retirees.
6) It appears that AIBRF has negotiated the above scheme without the knowledge of CBPRO, UFBU, IBA or government , leave alone their consent. It is against the commitment of common approach agreed among all apex level retiree organizations to present a unified face of retirees’ at the industry level, notwithstanding arrangement at individual bank level. AIBPARC cannot and ought not be party to any privately negotiated insurance scheme that has uncertain future where the retiree organizations have to fend for themselves and have to be at the mercy of an insurance broker.
7) The fine prints are to be read carefully including on co-pay, exclusions etc to detect the pitfalls and there is no reason why New India Assurance Co. that failed to quote a lower bid to IBA is willing to quote a lower premium to an insurance broker unless there lies hidden behind the terms and conditions that the settlement amount will be far less than obtaining in UIIC. It is to be noted that relation between premium quotes and the quantum of claims settled in the past cannot be ignored.
8) The prorate clause has to be understood for its serious implication. Here, Insurance companies make payment of all hospital charges (except MRP indicated items like medicine) in the same proportion of room rent eligibility bears to actual room rent when the latter is high. If actual rent is Rs.5000 per day and the rental eligibility is Rs.4000 per day and all other medical charges excepting medicine is Rs.200000, the insurance company will settle only Rs.1,60,000 entailing a loss of Rs.40000 because of the proportionality principle settling claim in the proportion rental eligibility of Rs.4000 bears to actual rent of Rs.5000. If the rental eligibility is Rs.5000 there would have been no loss in the above scenario. In the broker sponsored scheme, the room rent is Rs.3000 and Rs.4000 for the cover of Rs.3 lac and 4 lac respectively. Concern for hygiene and privacy make most opt for single occupancy where the rents in good hospitals for treating serious ailments are way more than Rs. 3000 and Rs.4000. So the rental eligibility of only Rs.3000 or Rs. 4000 in the context of prorate clause matter a lot.
9) Availability of Super top up and its rates are not yet finalized in the broker sponsored scheme.
10) Any scope for conflict of interest has to be scrupulously avoided by any union. While AIBPARC or CBPRO can be for participation by the collective of retiree organization in any negotiation by IBA with the insurance companies they are not for any individual retiree organization privately negotiating a scheme giving up their watch dog role.
In the above circumstances, our advice to the retirees is to stick to IBA group insurance scheme and believe in their collective strength and wisdom to obtain reliefs from IBA in the near future.
S.B.C.KARUNAKARAN
(Working President- AIBPARC)
(General Secretary- ARISE)

01/10/2019

One of my relatives was hospitalized on 25th September 2019 for treatment of typhoid. She opted for cashless treatment at a network hospital under Baroda Health Policy with Mediassist TPA. The hospital lodged initimation with estimate of expenses. On 26.09.2019, a query was raised by TPA asking for the need for hospitalisation. The treating doctor submitted his detailed reasoning. The TPA thereafter kept silent and there was neither denial nor approval given to hospital. On 29th September 2019 evening, the TPA informed that the premium towards policy was not paid last year. Immediately the hospital once again submitted a copy of policy and raised doubt as to how it was issued without receiving premium. No reply came till 30th evening conveying approval of cashless treatment. The patient was thereafter discharged on 1st October morning. When a known insurance agent was requested to expedite approval on 29th September, he disclosed that Mediassist TPA has been regularly delaying decisions in such cases. Ee have decided to refer the issue with this example to IRDA and fight till end till the TPA is punished. This is posted here for everybody to know the evil game by TPAs, particularly Mediassist TPA.

15/07/2019

The District Consumer Disputes Redressal Forum has slapped compensatory cost of Rs 2 lakh on Religare Health Insurance Company Limited for denying reimbursement of a genuine claim by a city-based senior citizen
Kamini Mehta.

Rejecting senior citizen’s claim costs health insurance firm dear CHANDIGARH: The District Consumer Disputes Redressal Forum has slapped compensatory cost of Rs 2 lakh on Religare Health Insurance Company Limited for denying reimbursement of a genuine claim by a city-based senior citizen. The insurer has been told to deposit the amount with PGIMER’s cardiology department for use in the treatment of needy patients.

They were also directed to reimburse an amount of Rs 2.91 lakh to the complainant with interest @12% per annum from the date of repudiation — October 22, 2018 — till payment, along with the litigation cost of Rs 10, 000.

Ram Swarup (61) of Sector 47-D stated that he had taken a health insurance policy from the firm in 2015 and got it renewed from time to time. It was averred that the complainant was operated for knee surgery on October 22, 2018 at Max Super Speciality Hospital, Mohali, and was admitted there from October 21 to 27, 2018.

However, the pre-authorization request of cashless hospitalization of the complainant was denied by the insurer on October 22, 2018, on ground of non-disclosure of material facts/ pre-existing disease, whereas he was covered under cashless health insurance policy issued by them. As such, the complainant, when discharged on October 27, 2018, had to make the payment of Rs 2.91 lakh to the hospital towards his medical treatment bill. It was submitted that the complainant, thereafter, requested the insurance company to pay his claim, but to no avail.

The company in its reply stated that after going through the documents given by the complainant, it was found that Swarup had not disclosed the fact that he was a hypertension patient at the time of taking the policy, which the complainant revealed during his pre-anaesthesia check-up. The reply added that Swarup is on regular medication and has been suffering from diabetes T-II DM for the past 8 to 10 years, but he didn’t disclose the same when he took the policy.

On hearing both the parties, the forum took notice of the fact that the insurance company, which has its own investigating agency and in-house panel of doctors to check the claims raised under the policy, never consulted them while issuing the policy to a person aged more than 60 years where the degeneration changes are bound to occur and definitely the gravity of the same varies from person to person. “Once they committed to indemnify the claim, if any, without going into the requisite enquiries, then they shall not be allowed to shun their responsibility to indemnify the claim raised during the coverage period,” the forum held.
(Ref: Health World - FB)

12/07/2019

https://www.dnaindia.com/ahmedabad/report-ahmedabad-consumer-forum-tells-insurance-firm-to-pay-full-claim-2759085

Ahmedabad: Consumer forum tells insurance firm to pay full claim - It should be noted that PPN rates are offered towards cashless medical claim made by those insured by government health insurance companies

10/10/2018

Revised rates for bank retirees policy

07/05/2018

पिकासो (Picasso) स्पेन में जन्मे एक अति प्रसिद्ध चित्रकार थे। उनकी पेंटिंग्स दुनिया भर में करोड़ों और अरबों रुपयों में बिका करती थीं...!!

एक दिन रास्ते से गुजरते समय एक महिला की नजर पिकासो पर पड़ी और संयोग से उस महिला ने उन्हें पहचान लिया। वह दौड़ी हुई उनके पास आयी और बोली, 'सर, मैं आपकी बहुत बड़ी फैन हूँ। आपकी पेंटिंग्स मुझे बहुत ज्यादा पसंद हैं। क्या आप मेरे लिए भी एक पेंटिंग बनायेंगे...!!?'

पिकासो हँसते हुए बोले, 'मैं यहाँ खाली हाथ हूँ। मेरे पास कुछ भी नहीं है। मैं फिर कभी आपके लिए एक पेंटिंग बना दूंगा..!!'

लेकिन उस महिला ने भी जिद पकड़ ली, 'मुझे अभी एक पेंटिंग बना दीजिये, बाद में पता नहीं मैं आपसे मिल पाऊँगी या नहीं।'

पिकासो ने जेब से एक छोटा सा कागज निकाला और अपने पेन से उसपर कुछ बनाने लगे। करीब 10 मिनट के अंदर पिकासो ने पेंटिंग बनायीं और कहा, 'यह लो, यह मिलियन डॉलर की पेंटिंग है।'

महिला को बड़ा अजीब लगा कि पिकासो ने बस 10 मिनट में जल्दी से एक काम चलाऊ पेंटिंग बना दी है और बोल रहे हैं कि मिलियन डॉलर की पेंटिग है। उसने वह पेंटिंग ली और बिना कुछ बोले अपने घर आ गयी..!!

उसे लगा पिकासो उसको पागल बना रहा है। वह बाजार गयी और उस पेंटिंग की कीमत पता की। उसे बड़ा आश्चर्य हुआ कि वह पेंटिंग वास्तव में मिलियन डॉलर की थी...!!

वह भागी-भागी एक बार फिर पिकासो के पास आयी और बोली, 'सर आपने बिलकुल सही कहा था। यह तो मिलियन डॉलर की ही पेंटिंग है।'

पिकासो ने हँसते हुए कहा,'मैंने तो आपसे पहले ही कहा था।'

वह महिला बोली, 'सर, आप मुझे अपनी स्टूडेंट बना लीजिये और मुझे भी पेंटिंग बनानी सिखा दीजिये। जैसे आपने 10 मिनट में मिलियन डॉलर की पेंटिंग बना दी, वैसे ही मैं भी 10 मिनट में न सही, 10 घंटे में ही अच्छी पेंटिंग बना सकूँ, मुझे ऐसा बना दीजिये।'

पिकासो ने हँसते हुए कहा, 'यह पेंटिंग, जो मैंने 10 मिनट में बनायी है इसे सीखने में मुझे 30 साल का समय लगा है। मैंने अपने जीवन के 30 साल सीखने में दिए हैं ..!! तुम भी दो, सीख जाओगी..!!

वह महिला अवाक् और निःशब्द होकर पिकासो को देखती रह गयी...!!

एक प्रोफेशनल या सलाहकर को 10 मिनट के काम की जो फीस दी जाती है वो इस कहानी को बयां करती है।

एक प्रोफेशनल या सलाहकार के एक काम के पीछे उसकी सालों की रात दिन की मेहनत होती है ।

क्लाइंट सोचता है कि बस जरा सा काम ही तो होता है फिर इतनी फीस क्यूँ लेते हैं !!!

Dedicated to all Professionals and apt for profession

21/04/2018

Cake cutting on second anniversary of BHP Mediklemz

07/04/2018

It is for information of all that a laboratory tests report submitted with reimbursement claim needs to be signed by a MD, Pathologist. Else it will not be considered for settlement of the claim.