If you are persistent you will win

The health insurance claim of Sanjay (name changed) was rejected by the insurance company. Repeated attempts by the insured with insurance company at various levels were not successful. We as Insurance Brokerage Firm advised him to take up the matter with Insurance Ombudsman. The matter took some time as the office of Insurance Ombudsman is having large number of complaints or cases coming up every day. After processing the date were fixed, the case was taken up and finally the insurance company was ordered to pay the claim. We appreciate the persistence effort put in by the insured, which has brought success to him.

Outlook magazine of November 3, 2011 has carried the case of Dr Kunal Saha, a medical doctor working and residing in USA. His wife had died in Kolkatta in 1998 while undergoing treatment. Kunal was convinced that Dr. Sukumar Mukherjee, the top Kolkatta physician who first treated Anuradha, had inflicted on her a massive overdose of Depomedrol, a long acting corticosteroids that went on to play havoc with her immune system; and that the treatment that followed, involving other doctors and the Advanced Medicare Research Institute (AMRI) a reputed private hospital, had been appallingly negligent .Armed with both certainty and rage, Saha, himself, a Kolkatta trained doctor put his peers in the dock.

Saha had too traveled 50 times over 13 years to India to fight the legal battle. I admire this gentleman.

The claim of Saha was for Rs 77 crores but Supreme Court of India delivered a ruling in 2009 which vindicated his struggle. By finding the Kolkatta doctors negligent, it opened the door for compensation order to be passed.

In October 2011, National Consumer Redressal commission has ordered that three Kolkatta doctors who treated Anuradha and AMFI will have to pay Rs 1.73 crores. Net payment after deductions to Saha will be Rs 1.34 crores. According to Dr Kunal Saha the amount spent by him on legal battle has been of the order of Rs 5 crores.

The points coming up before us are;

1. We should be persistent in follow up of our case whether it is Health insurance claim against an Insurance Company or liability claim against someone, who has not performed his duty.

2. Were 3 doctors or AMFI having professional liability cover in 1998 from Insurance Company? If yes will the Insurance Company pay it?

Let us wait and watch.

Are they supporting each other Or are they fighting with each other?

Recently we came across a news item that 64% of the cases which came up before Insurance Ombudsman (located all over the India) was pertaining to health insurance portfolio. Let us look at the facts;

Health Insurance as % of non life insurance portfolio = 32%
Group policies issued under Health Insurance portfolio = 50%
Policies issued to Individual/ Families = 50%

It means policies being issued to Individuals/ Families are only 16% of total non life insurance portfolio.

General impression is that claims arising from group policy get paid because they have the bargaining /negotiating power .It means that Individuals/ Families are the worst sufferers as this is the group which is having claims being disallowed.

The question before us is how many of the dissatisfied customers are able to reach the office of Insurance Ombudsman?

64% figure is really a very high figure .Let us try to look at the reasons for this scenario or why it is so?

There are 3 players.

Role of every player is to provide good service to the customer. When the insured has to go in for hospitalization then each one ( Insurance Company /TPA/Health care Provider ) is trying to pass on the buck to other player as if the objective or job description of each one is who can harass the customer most so that he runs away and forgets about claim .
Health care provider says that this insurance company is blacklisted or this TPA is black listed

TPA says that this health care provider is black listed.

Insurance Company says that they are ready to consider the payment of the claim but it will not be on cashless but on reimbursement basis. This defeats the basic assumption of the client that when the need arises he will be able to have payment coming from insurance company.

We need the change in thinking at all levels.