[TKMCE]

I had a bad experience in my first ever claim of medical insurance in my family. Hence need your opinion on a couple of points.

1 The responsibility of the agent who sold us the policy. Does his responsibility stop the moment the initial policy is sold ? This was a policy for a cover of 1 Lakh for my mother-in-law who is a senior citizen. This was the first claim after we purchased the policy for her 7 years ago The same agent is listed as the intermediary in the latest renewed policy document also.

2 The responsibility of the hospital insurance desk. This relates to a very reputed hospital in Kerala. We had shared the policy documents 10 days before actual hospitalization for removal of uterus, after they confirmed cash less facility was available with our insurance company. Infact they first got what they said was an "initial" approval of 25000 from the insurer's Third Party Administrator (TPA) post which my mother-in-law got admitted for the procedure.


Since as mentioned this was my family's first ever insurance claim case, we had repeatedly checked both with the agent and the hospital insurance desk well in advance about any restrictive clauses and nothing was informed to us by either party.

What happened in the end ?

Surgery went off well. In 2 days, discharge happened. Bill in total came to Rupees 1 lakh 4 thousand. The hospital insurance desk sent the final claim amount to the insurer's TPA and the decision came in three hours.

REJECTED. NO FURTHER CLAIM OTHER THAN THE INITIAL 25000 approved is possible.

REASON ?

SUB LIMIT UNDER HYSTERECTOMY EXHAUSTED.

So in effect of the total bill of Rs 1,04,000 I have to pay 79,000.

Now no one in my family studied medicine. Since the rejection by the TPA was emphatic, I had no choice (although I knew it was too late) but to go through the fine print.

There it was ...Under "Sub limits" there was the clause that for Senior Citizen policies Hernia and Hysterectomy claims are limited to 25% of the sum insured with a maximum limit if 1 lakh. Google obligingly told me Hysterectomy is the medical term for "removal of uterus"

So TPA was right and I have decided to pay up.

But we did check with the insurance desk supervisor at the hospital why they did not check the policy document about sub limits (the document was given to them 10 days before the operation at THEIR request) and her answer was "we check only page 1 and page 3 of the policy and nothing else" and closed the case.

Now I find this ridiculous.

If every purchaser of medical insurance has to check every single thing themselves what is the need for an agent or the hospital insurance desk? In my case it was clear neither the agent nor the hospital had bothered to check the sub limits. Also the TPA of the insurer when we tried to have some queries answered through them prior to hospitalization informed us that any queries for cashless claims have to come through hospital only.

So does this mean

1 The insurance agent's responsibility stops the moment the policy is sold first time ? The agent once told us he gets 15% of every renewal premium we pay as his commission. So in effect does this mean we have been indirectly paying this guy all this time for NOTHING ?. Is there any way I can complain about this agent to IRDAI or the insurance company as his other customers can also suffer the same fate ?

2 As mentioned the TPA told us (we have an email) that all queries regarding cashless claims have to come through the hospital. But does that also mean the hospital insurance desk has no responsibility to check exclusions/sub limits. Infact if they had bothered to check the sub limits, they would have realized there was no basis for the second claim itself since amount possible was already exhausted in the first claim. Now the insurance help desk supervisor is saying it is us, the patient and family who have to be familiar with the exclusions and restrictions and not the insurance desk. I have complained about this to the hospital top management but honestly, I don't expect anything to come out of it and therefore I am paying up in the 5 more days I have left.

Your valuable inputs will be apprreciated.

[shivmarwaha]

I came across star health opd plan. Has anyone taken that and can advise

[whitewing]

Originally Posted by TKMCE

...
1 The insurance agent's responsibility stops the moment the policy is sold first time ? ..

Your frustration is understandable. However, the recourse is limited.
If you were mis-sold the policy, then you could complain against the agent with the insurance provided.

One would have expected the hospital and the agent to be better informed about the exclusions. But, I don't think they are legally liable to these.

Unfortunately, the reality we live in is that - we have to be familiar with the exclusions and restrictions.

[Latheesh]

I have a family floater insurance from ICICI and received this couple of days back. I have this insurance cover outside my employer insurance (started around 10 years back) and zero claim till now.

[saket77]

Originally Posted by Latheesh

I have a family floater insurance from ICICI and received this couple of days back. I have this insurance cover outside my employer insurance (started around 10 years back) and zero claim till now.

I paid recently for a ~22% hike in my family floater policy. No recent claims.

[Ays7]

Originally Posted by saket77

I paid recently for a ~22% hike in my family floater policy. No recent claims.

I usually, since last 15 years am used to paying Insurance premiums only once every 2/3 years, meaning I pay for a plan for 3 years or 2 years depending on what company offers, usually HDFC Ergo. Till first 10 years, there were no hikes whatsoever and premiums were steady, but last 2 renewals have seen premiums rise substantially. So yes, I think IRDA has approved rise in premiums for policies due to which this has been happening even when there is no claim or no change in age brackets.

[dass]

Originally Posted by saket77

I paid recently for a ~22% hike in my family floater policy. No recent claims.

Originally Posted by Latheesh

I have a family floater insurance from ICICI and received this couple of days back. I have this insurance cover outside my employer insurance (started around 10 years back) and zero claim till now.

In my case, I crossed over the 45 years bracket and my premium shot up 33%. No claims for the past 3 years now. I realized this a little too late to check for other options. This hike is no way justifiable, so I will be looking at other options when this policy is up for renewal.

[ValarMorghulis]

Originally Posted by shivmarwaha

I came across star health opd plan. Has anyone taken that and can advise

Star health is poor in honouring claims. Avoid.

[ZMG]

Hi
Is there a way I can change my agent ? I have ICICI insurance, and have renewal next year in June.
My agent has been absolutely useless in answering questions, and I do not want to continue with him at all.

[GutsyGibbon]

A few queries I have that I hope an expert can clarify. I am a US citizen with OCI, I intend to spend ~175 days in a calendar year in India. Are there health insurance plans for 6 months that I can buy? If there is no continuous coverage does it matter? Does it make sense to buy continuous coverage even though I do not plan on using it throughout the year?

[Way2Jimny]

Originally Posted by TKMCE

REJECTED. NO FURTHER CLAIM OTHER THAN THE INITIAL 25000 approved is possible.

REASON ?

SUB LIMIT UNDER HYSTERECTOMY EXHAUSTED.

So in effect of the total bill of Rs 1,04,000 I have to pay 79,000.

Can understand your frustration. Unfortunately, most of us pay insurance premiums and don't understand the rules of the policy until we end up with a claim.
Many of the diseases have sub limits mentioned.

For example, Start Health Senior Citizen Red Carpet was one of the early providers of insurance to senior citizens. See below an extract of limits from their policy wordings.

https://web.starhealth.in/sites/defa...t-Brochure.pdf

Under this policy, If someone wants to claim for cancer treatment, if they have a coverage of 25 Lakhs, they are eligible to claim only 5 Lakhs for treatment.
For Cataract, you can claim only 40K even if you have coverage for 25L.

I urge everyone to please read your policy wordings and limitations. Take corrective actions and move to a better policy before its too late.

[Satkaj]

Originally Posted by ZMG

Hi
Is there a way I can change my agent ? I have ICICI insurance, and have renewal next year in June.
My agent has been absolutely useless in answering questions, and I do not want to continue with him at all.

Find a new agent. He will do the needful with your insurance company. You will be asked to sign a form. I changed my agent 2 yrs back and the process was hassle free.

[SideView]

My friend and me and our familes are looking for medical insurance.

I have coverage under my company, but does it make sense to buy a floater ? Any recommendations based on experience.

Thanks.

[JMaruru]

Originally Posted by GutsyGibbon

A few queries I have that I hope an expert can clarify. I am a US citizen with OCI, I intend to spend ~175 days in a calendar year in India. Are there health insurance plans for 6 months that I can buy? If there is no continuous coverage does it matter? Does it make sense to buy continuous coverage even though I do not plan on using it throughout the year?

I have been maintaining my private health insurance in India for 10+ years now, even when I have my US health insurance running concurrently. I stay for around 6-8 weeks in India, every year. I haven't found a health policy which covers for only certain period of an year. You could look for travel health policies.