Insufficient Claim Amount sanctioned by NIC

[mayur.gp]

My father has a Mediclaim Policy from NIC with total sum insured of Rs. 3 lac/-. The sum insured was enhanced in the period 2011-12 ( from Rs. 1 lac /- ) through an increased premium . A mediclaim was raised in august '14 with Emeditek as the TPA . The claim amount sanctioned was just Rs. 1 lac /- . Upon inquiry it was observed that 2011-12 policy document was not acknowledged due to oversight by the NIC & TPA while determining the approved claim amount ( since, in order to be eligible for the enhanced sum insured , a period of 2 yrs. need to pass ) . How to go about reimbursing the balance 2 lacs /- in a quick time ??????

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[Expert]

The claim amount sanctioned was just Rs. 1 lac /-

Generally, a TPA will accept to pay only part of the sum required for the treatment of the patient, and settles the final bill with the hospital after the patient has been treated. In some cases if you exceed your policy assured sum, you will be required to pay the excess amount. If your policy does covers the required sum, and your TPA has not sanctioned a sum large enough to cover the initial cost of your treatment the hospital will ask for the sum to be increased.

[Expert]

How to go about reimbursing the balance 2 lacs /- in a quick time ??????

Follow up with you TPA and follow below rules:
1- It is your hospital’s responsibility to provide a reasonable justification for the treatment you are undergoing.
2- All documents including, medical bills (given to the patient’s relatives in some cases), lab reports, claim forms and discharge papers need to be submitted to the hospital before discharge.
3- Remember to keep a copy of all the above for future reference.
4- If your TPA does not accept your claim, you can pay and then apply for a reimbursement from the insurance company later.