New India Assurance has paid Rs34,313 towards a mediclaim that was earlier rejected by the TPA on flimsy grounds. But, payment towards visiting charges and investigation were prorated based on room rent limit. Is it justified or is the TPA being unscrupulous?

Raj Pradhan

Sujit Banerjee (name changed), a retired senior citizen of 73 years of age, had approached the Moneylife Insurance Helpline seeking help with his rejected mediclaim on flimsy grounds by TPA (third party administrator). Due to Moneylife’s intervention, Mr Banerjee got a payment of Rs34,313 from New India Assurance, but the payment towards visiting and investigation charges were prorated based on room rent limit. Is it justified?

There will be reduction in payment for visiting charges and investigation depending on what was allowed for the room for which you were eligible, but should the payment be prorated? Policyholders need to check what the insurance policy wordings specify about room rent limit and its impact on other charges. If the mediclaim policy clearly states that the charges will be prorated if you avail a room with higher rent than your limit, then it is acceptable.

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