Corporate Group Health Claim: 15 Lakh Recovered for Employee After TPA Denial
A tech company's employee in Electronic City had a claim rejected by the TPA for a newly approved cancer treatment. The TPA called it 'experimental' despite IRDAI approval. We escalated directly to New India Assurance, bypassing the TPA, and got full payment within 45 days.
The Situation
40-year-old software engineer diagnosed with rare cancer. Treatment approved by DCGI and IRDAI but TPA rejected as 'experimental/non-standard'. Employee's group policy sum insured: 15 lakh. HR helpless — TPA controls process.
The Challenge
Bypass TPA denial and get insurer to honor IRDAI-approved treatment. Prove TPA overstepped authority.
How We Solved It
- Obtained DCGI and IRDAI approval letters for the specific treatment protocol
- Cited IRDAI circular: TPA cannot override IRDAI-approved treatment coverage
- Wrote directly to New India Assurance CMD bypassing TPA
- Got company HR to issue supporting letter on company letterhead
- Filed complaint with IRDAI Grievance (Bima Bharosa) against TPA
The Result
New India Assurance settled 15,00,000 directly to hospital within 45 days. TPA's denial overruled. Insurer issued circular to TPA network on IRDAI-approved treatments.
Key Lessons
- TPA is an administrator — cannot override insurer's coverage obligations
- IRDAI-approved treatments MUST be covered regardless of TPA opinion
- Escalate directly to insurer when TPA denies valid claims
- Corporate HR letter on letterhead carries weight with insurers
Client Testimonial
"The TPA said 'experimental' but IRDAI had approved it. My HR couldn't help. Hari Sir wrote to the insurance company directly. They paid the hospital in 6 weeks and told the TPA to update their guidelines."