How to complain if your Health Insurance Claim is denied
You have just had surgery and are trying to recover when you hear that your Health Insurance company has denied your claim! Indian Health Insurance companies are denying (or partially paying) more and more claims. Here are some suggestions on how to deal with such a situation.
Things You'll Need
- Copies of your Claim Forms and all Supporting Documents from the Hospital, Surgeon and other Medical Expenses
- Negotiating Skills
- Tenacity to fight for your rights
Steps
Write to your Insurance Company
If your Health Insurance claim is denied or partially paid by the Third Party Administrator (TPA) write to the Insurance company within 15 days. Provide them with copies of all documentation and claim forms submitted to the TPA. In your letter specify why in your opinion your claim should be honored, set a timeline and the next steps you will be taking if you don’t hear from the Insurance company. Please be polite in your message and request the Insurance company to address your grievance in a timely manner. Make sure you send your letter via registered post.
Post to a Consumer Forum on the Internet
You should also post your grievance on a Consumer Complaint Forum like the Indian Consumer Complaints Forum. Please be polite in your message and request the Insurance company to address your grievance in a timely manner. Insurance companies do not like bad publicity and since your complaint has the potential of discouraging future customers, there is a good chance that they will contact you and attempt to settle your dispute.
Contact the Insurance Ombudsman for your region
India's Insurance Regulatory and Development Authority has created the office of Insurance Ombudsman who can rule on Insurance Claim disputes for all Health Insurance companies operating in India. This is a quick way of addressing consumer complaints about Health Insurance, without having to go to court. While the decision of the Ombudsman is binding on the Insurance Carrier, the consumer still has the option to go to court if the Ombudsman’s decision is not acceptable to them. You can write a complaint to them 1 month after contacting your Insurance carrier. To find out the contact information for the Insurance Ombudsman for your region visit the IRDA website.
File a case in a Consumer Court
If you are not satisfied with the decision by the Insurance Ombudsman then you still have the option to file a case in a Consumer Court. You will need to consult a lawyer at this point to file a case.
Tips
- Always have all communications in writing. Keep copies of all documents for your record and always use Registered Mail (with acknowledgement due) to ensure that you have proof that the other party has received your mail.
Caution
- It is always better to negotiate hard with the TPA and the Insurance company to settle the claim instead of going the legal route.
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