The things nobody tells you
Every week Sandeep writes about one moment in a claim where people lose money they didn’t have to. Not because the cover was missing, but because nobody told them what to ask. A few of the lessons he comes back to most:
Rejected and paid less are different letters
Most people who say their claim was rejected were actually paid less than the bill. A deduction has a reason tied to a clause, and you are entitled to see which one.
You cannot argue with a number you have not been shown the arithmetic for.
The first approval is not the final one
The amount approved at admission is based on the hospital's estimate before treatment. If the stay runs longer, the hospital asks again, and that is a fresh assessment. Ask to be told the moment it happens.
The gap is usually explainable. It is almost never explained.
Write to whoever can change the answer
Your policy is a contract with the insurer, not the TPA on your health card. When a claim goes wrong, write to the insurer's grievance officer and copy the TPA, not the other way round. If your company has a broker, that letter is their job.
Address your letter to whoever can actually change the answer.
Collect the file on discharge day
Reimbursement claims stall on small things: a bill without its breakup, a missing report, a prescription nobody kept. Ask for originals and the itemised bill, and photograph every page before you hand it over.
The documents are easy to get on discharge day and hard to get ever again.
Day care is its own category
Many treatments no longer need a 24 hour stay, and policies cover a list of them as day care procedures. The list differs from policy to policy, so before any planned procedure, ask whether it is on yours.
A benefit nobody claims is the same as a benefit nobody bought.
Cover ends on the last working day
Group health cover stops when someone leaves, and almost nobody says so in the exit conversation. Arrange personal cover while you are still covered, so the waiting periods start running now.
Your health cover ends on your last working day. Arrange something before then.
General information, not advice on your own policy. What applies to you depends on your policy terms.
Three people, three chairs
The Ethika group was started in 2015 by three colleagues who left the same broking firm together. Eleven years on, all three are still here, each in a different chair.
Susheel Agarwal
Founder and CEO. Looks after people.
Read about SusheelSarath Reddy
Co-founder. Looks after clients.
Read about SarathSandeep Mukka
Co-founder and Principal Officer. Looks after operations.
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