Herclon not paid by Insurance Company(TPA) saying Hospitalization is not required for taking it,so rejected.

[shashishekhar]

I have group insurance policy of National Insurance provided by my company. Concerning TPA is "E Meditek Insurance TPA Limited.

My wife is a patient of Breast cancer & her treatment is going on. She is taking maintenance trastuzumab (1yr Course) & now only 4 cycles are remaining.

When she was taking Trastuzumab (Herclon) along with other chemo drug Paclitaxel then all claims are paid by E-Meditek but now when she is taking only Herclon, they refused my claims saying that " HOSPITALIZATION IS NOT JUSTIFIED ONLY FOR TAKING HERCLON INJECTION".

Please note that my wife has been taking Herclon after regular admission in hospital or as Daycare basis as & when required (for need of pathology tests etc.). At the time of refusal the cashless claim of Daycare treatment , their version is "HOSPITALIZATION IS NOT JUSTIFIED ONLY FOR TAKING HERCLON INJECTION AS IT IS NOT INCLUDED IN DAYCARE LIST".

When I asked for detail Daycare Procedure List from senior officials of E Meditek through written letter, they has not responded my email. I have alsoapproached the person who facilitate the group medical policy matters from my company but perhaps he do not understand my concern & said that EMeditek's doctors are right.

I think that this total matter is based on "Whether Hospitalization is required for taking Herclon or Not". Please let me know that whether Insurance company or its TPA can decide that hospitalization is required in particular case or taking particular drug or not.

I have claimed some similar claims from my private medical insurance (from different company) & they paid whole the claim, but now when this insurance has been exhausted & when I tried to take claim from E Meditek,they refuges.

Please anybody help me what I should do in this case.

Regards,

Shashi Shekhar Mishra

[kontak TeamBCI]

Hi Shashi - not aware much in this matter. Lets see if anybody from our forum can help

[roxboxfox RadiationOncologist]

If you have a grievance, approach the grievance cell of the insurance company first.

If you are not happy with their solution, you can escalate the matter to IRDA.

Give your complaint in writing along with the necessary support documents

Take a written acknowledgement of your complaint with the date.

The insurance company should deal with your complaint within 15 days.

If that does not happen or if you are unhappy with their solution you can:

Approach the Grievance Redressal Cell of the Consumer Affairs Department of IRDA:

Call Toll Free Number 155255 (or) 1800 4254 732 or

Send an e-mail to [e-mail]

Make use of the Integrated Grievance Management System:

Register and monitor your complaint at igms.irda.gov.in

[AjayKK in reply to roxboxfox]

Thanks for your assistance. Please clarify your second point i.e. "Make use of the Integrated Grievance Management System:". What is this actually?

Can we get quick reply from IRDA because our Indian legal system takes long time to resolve cases.

I have seen number of approved and rejected cases for same treatment. Is there any standard norms and rules for all insurance companies or different rules for each any every insurance company? Because I have provided proof to my insurance company saying that other insurance company approved claim for same treatment then why my claim you rejected.

Please assist because same problem I am also facing since 3 months.

[roxboxfox RadiationOncologist in reply to AjayKK]

What is Integrated Grievance Management System?

The Integrated Grievance Management System (IGMS) is an online consumer complaints registration system created by IRDA. All insurance companies have integrated their online complaint logging systems to the IGMS maintained by IRDA. Policyholders can register their complaints online with their insurance company and track the progress of complaint resolution. IRDA monitors the complaints and their progress in real-time through IGMS.

How do you use IGMS?

You can make best use of this system by giving accurate information about your complaint like the policy number, name of the insurer and your contact details.

The Complaint Registration Process involves the following TWO SIMPLE steps

Step 1: Register yourself by entering your details

Step 2: Register your complaint and view its status

What should you do in case you have a complaint against an insurer?

First approach the insurer’s Grievance Redressal Mechanism. This is given in your insurance policy document. You can also get the Grievance Redressal Mechanisms of all insurers at the following links.

Grievance Redressal Mechanism: Life Insurers

Grievance Redressal Mechanism: Non-Life Insurers

What if there is no response from the insurer?

If the complaint is not fully attended to by the Insurer within 15 days of lodging it, please use IGMS for escalating the complaint to IRDA.

[kumar121]

As far as I have experienced, insurance company try to evade through minute loopholes.

trastuzumab is covered under insurance & do consider 24hrs hospitalization as they may point out this is not a chemo medicine and can't be considered as day care medicine.

If you face issue reach out to insurance Grievance cell. If still not satisfied means contact your locality's Insurance Ombudsman office of IRDA

[pprabhu]

Hello.. Refer these links on similar discussion this may help:

healthunlocked.com/breastca...

healthunlocked.com/breastca...

[Sherna]

My entire trastuzumab course was paid by my insurance company so I see no reason why yours should not be as well. Insurance companies are notorious for dodging payments when they can. Take the matter to the grievance cell of your insurance company and if they reject your claim as well then take it before the insurance ombudsman in your city.

[Saiprasad in reply to Sherna]

Which company`s insurance u have and which product..?

[roxboxfox RadiationOncologist]

Approach Insurance Ombudsman

This nuisance of not paying has been going on for the last 10 years.