Today I came across a claim under mediclaim which was not settled since a long time. The reason is " data not available" with the insurer.
This set me thinking. How can data be not available? The divisional offices send the data to Z.Os who in turn send it to C.O. Let us examine it closely.
Suppose at the beginning of April 2014 " X " number of employees are covered. It is possible there are exits .. say " Y." So as at the end of the year X minus Y number of employees/pensioners must be there in respect of whom the premium was received. The names/data pertaining to all these (X - Y ) must be available with the insurer. When premium in respect of all these insured persons was received, reconciled and taken into credit, how can the Insurer say " Data is not available" in respect of a claimant?
So something wrong somewhere. Is the insurer simply adjusting the entire amount of premium without reconciling the lists of insured persons and without caring for missing data? OR is it our LIC is remitting the entire collection without tallying the lists and checking for purity of data?
What I said above i.e., the claim being pending is the case of an employee in service. The employee paid the hospital charges out of his pocket and is waiting for claim to be settled. As the patient was discharged no advance is payable even if it is kept pending for no fault of the employee.
IF THIS WERE TO BE THE CASE OF AN EMPLOYEE IN SERVICE, JUST IMAGINE THE
PREDICAMENT OF A RETIRED PERSON IN SIMILAR SITUATION? Pensioners do not get any advance against mediclaim benefits. So it becomes imperative that our organisations examine in depth how the scheme is being administered and what are the flaws.
The issue of identity cards by TPA for emergency medical help in case of the 6 contingencies covered for cashless service, is yet to begin. Add to this difficulty the eventuality of " data not being available."
Is it not time that we ask for a confirmatory letter from LIC that not only full premium is received but the name/s of beneficiaries also are included and sent to the Insurer?
The work relating to Omission of Data is being handled by C.O. The Insurer takes his own time to process the data and how fast this will be handled depends on conditions in their offices. Meanwhile why should claims be kept pending for want of " data?"
Under SSS policies payments were released based on certificate of recovery of premia by the employer. Why cannot NEW INDIA settle such pending claims based on a certificate of receipt of full premium by LIC ? This may become necessary till the data with LIC and Insurer becomes identical. In my anger about the inadequacies of the scheme in implementation stage it is possible I omitted some aspects. I request brother pensioners who are more knowledgeable to point out any omissions by me and tell how best the scheme can be perfected.