Violations by IFFCO TOKIO General Insurance Co. Ltd.-Group Mediclaim Policy 2015-16

We have come to know from the retired  members of MAFS that the present Insurance company -IFFCO Tokio- with whom the GMP contract for the period 2015/16  has been renewed-  has initiated  restrictive practices regarding settlement of their pre-authorisation  bills with Network Hospitals. Some other  unauthorised practices have also been observed in cases relating to   planned hospitalisation such as, Cataract Surgery and other procedures where  hospitalisation under a package  are agreed to  by the retiree members. In this connection, we emailed  to central office members’  concern in the matter. Some extracts form the emailed letter are given below.

“Earlier where treatment of cataract surgery was planned, the TPA
(under United India Insurance co.) used to provide for the entire admissible  amount in one instalment capped at  RS 40000/- on submission of the required case papers  by the  hospital…”

“Our  members who have undergone cataract surgery in the  network hospitals have reported  that the amount estimated  by the hospitals is not being released by the TPA in one go as was being done by the same TPA under  earlier Insurance company. In a recent case (details in Annexure I), where the TPA (Medi Assist, Noida) approved the pre estimated amount as conveyed to them in 3 instalments, that too 60% of the amount claimed by the hospital. The balance amount was sanctioned 5 hours after the surgery was performed. Till then the  patient remained stuck in the hospital. He was thus  forced to expose himself to the avoidable risk of aggravation/infection. It is well known in Health Care Industry that  the cataract treatment is a fixed package where the cost of lens and surgery charges, as a rule, are pre-fixed, and there is little  scope for  any subsequent changes in the estimates.”

We have also reports and papers which prove that United India Insurance is a better rated company by the Health Care Industry and enjoys a higher credit limit than the present insurance company.Our members are also at a loss to  understand  the favour bestowed upon a Company in Private Sector and all love lost for Public sector Company owned by the nation, when  generally the beneficiary employees were satisfied by the implementation of the policy by the Public sector Company since the inception of the scheme. 

As per the  guidelines issued by Insurance company to TPA, under the pretext of  Package System, TPA has reduced the Cashless Facility and the Hospitalisation limit of the retirees to a farce . In fact,  by  disallowing  the genuine claims of the retiree including that of medicines and investigation charges etc. the Insurance company is  violating  the provisions in the policy. Who has authorised the company to  sanction the pre-authorisation amount  on the basis of  the room rent below the  eligibility of the member concerned?

The difference in the amount between the eligible amount and actual paid amount for Room Rent/ICU/ICCU is also payable by Regional Office in accordance with the para.No.7 of C.O. Circular C.O.HRDD.No.G.100/4241/18.03.00/2010-11 dated November 1, 2010.

However, We have come across many cases where the members have not claimed the room rent difference from the Bank as they are not aware of the same. The instructions relating to retirees  are not well circulated, although central office invariably advises regional offices to bring the contents of such  circulars to the retirees’ associations. It is not being done as no retirees’ association is on the mailing list of  the Bank. Instructions remain  confined to a few in the Bank and the Medical Desk.

Or some times, the members who are coping with the prolonged  sickness are required to approach bank at different times  for settlement of the bills and  trivial objections involved.  Some consider it better to  avoid the hassles in representing and then fearing for the negative response.  They thank God for whatever amount is paid by the Insurance company. But this approach makes the Insurance company richer due to  their grace rather than God’s.

In the circumstances, retiree members who have undergone hospitalisation may note to  first  obtain the full itemised details of rejections along with reasons /summary of the settlement from the TPA. TPA is bound to provide the same as per Regulatory Authority’s guidelines. Then they should  represent each and every deduction /wrong settlement of their bills first to the TPA, and if rejected or not replied to within 3 weeks , to Central Office through their local office. We should also bring all such information about MAFS to the notice of  retirees in Class IV and Class III who are  already suffering due to very low room rent admissible to them.