Summary
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.
How We Solved It
S 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.
T Task
Bypass TPA denial and get insurer to honor IRDAI-approved treatment. Prove TPA overstepped authority.
A Action
- 1. Obtained DCGI and IRDAI approval letters for the specific treatment protocol
- 2. Cited IRDAI circular: TPA cannot override IRDAI-approved treatment coverage
- 3. Wrote directly to New India Assurance CMD bypassing TPA
- 4. Got company HR to issue supporting letter on company letterhead
- 5. Filed complaint with IRDAI Grievance (Bima Bharosa) against TPA
R 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.
Lessons Learned
- 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
"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."
— The TPA | Electronic City, Bangalore
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