Q: I took a health insurance cover paying a heavy premium with the assurance of cashless facility when hospitalised. I was admitted in an approved hospital and presented the identity card issued by the insurance TPA seeking cashless facility to the hospital authorities. The hospital authorities informed me that the TPA did not accede to my request denying cashless facility, stating “Cashless denied, Hospital not in GIPSA/ PRN Network.” I was asked to pay a minimum of ₹1 lakh immediately. After getting discharged, I wrote to the TPA informing them that the relative hospital is included in the network hospital list provided by them when the insurance coverage was taken. After several reminders they advised me to submit hospital bills and get reimbursement. I wrote to them of the trouble I was put to on the sick bed to arrange for monies demanded by the hospital, and demanded they refund the premium amount paid by me as they failed to keep up their assurance of cashless facility. There is no response from the TPA, despite reminders. May I have advice from your insurance specialists as to the remedy if any available for me in this regard, through your paper column, at the earliest.
B V NARASINGA RAO
A: You have two issues. One that your cashless facility was not forthcoming and two that you are yet to receive/ prefer your claim. Please write to the Grievances Officer of the branch of your insurance company where your policy is, with a detailed complaint. You have to do this in writing, either by post or e-mail, with all relevant information and copies of all supporting documents. Please ensure you get an acknowledgement of the communication
You will find their contact information on your policy document and also on the website of the Insurance Regulatory and Development Authority of India (IRDAI). You should expect them to respond to you and resolve the issue in about two weeks. If that does not happen, please escalate the issue to IRDAI through their online grievances facility called the ‘Integrated Grievance’.
Just to recap what was said in the column Cover Note some time ago:
“Every insurer has to have a policy for policyholder service parameters approved by its Board of Directors as mandated by the Insurance Regulatory and Development Authority of India (IRDAI).
The policy should specify turnaround times for various services to policyholders and an “effective Grievance Redressal Mechanism” to ensure that complaints are resolved in a time-bound and efficient manner.
Complaints to the Grievance Officer can be about dissatisfaction with the insurer, distribution channels, intermediaries, insurance intermediaries or other regulated entities about an action or lack of action about the standard of service or deficiency of service and the insurance company is required to resolve a grievance within two weeks of its receipt.”
If you are not satisfied with the response to your complaint, you can escalate it to IRDAI, which will take it up with the insurance company and facilitate a re-examination of the complaint and resolution.
You can call the IRDAI Grievance Call Centre on Toll Free Numbers 155255/ 1800 425 4732 that works from 8 a.m. to 8 p.m., Monday to Saturday and offers services in English and all major Indian languages.
You can send an e -mail to [email protected], or you can visit IRDAI’s consumer education website www.policyholder.gov.in and fill and submit the complaint registration form there.
You can post your complaint letter with copies of all supportings to The General Manager, Consumer Affairs Department – Grievance Redressal Cell, Insurance Regulatory and Development Authority of India (IRDAI), 4th Floor, Survey No. 115/1, Financial District, Nanakramguda, Gachibowli, Hyderabad – 500032.
IRDAI has also established an online complaints registering system called the Integrated Grievance Management System (IGMS) at www.igms.irda.gov.in where you can fill and submit a form with your complaint which will reach both the regulator and your insurance company, and so the IRDAI monitors consumer complaints in real time.
The system also lets you track the status of your complaint as the action taken by your insurer are updated on the system which alerts the various stakeholders on tasks and deadlines.
Your complaint should be resolved in two weeks and, if you don’t revert in eight weeks after that, the complaint will be closed by the insurance company.
If the company does not respond even after 15 days or if you are not satisfied with the action taken, you can escalate the complaint to IRDAI again and the regulator will take it up with the company for resolution.
You still can go to the Insurance Ombudsman or seek other legal remedies if the insurance company’s response is not to your satisfaction.
(K. Nitya Kalyani is a business journalist specialising in insurance & corporate history)
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