Struggling with Insurance Reimbursement for Son's Hospitalization During Maternity Leave – Any Advice?

When I was on maternity leave, after delivery, I had to hospitalize my son from 7th to 11th December 2012 (5 days) when he was 5 months of age. Post maternity leave, I resumed duty on 19th December 2012, and I added my son's name to the policy for medical insurance from Bajaj Allianz on the same day. Now, the insurance company is denying reimbursement for hospitalization, stating that my son's name was added after the hospitalization, i.e., on 19th Dec.

Query Regarding Insurance Reimbursement

As I was on maternity leave until 18th Dec, I could not inform them to add my son's name to the mediclaim policy. How can I get reimbursement for hospitalization?

Please share your views.

Regards

Dear Seniors, so many views but not a single reply. Please help me in getting reimbursement. We, female employees, can't inform the company immediately after delivery. Regards.

Communication Responsibilities During Maternity Leave

There was negligence on your part, I must say. It is your duty to inform HR of your delivery, at least by email. This age is far better than the past, and the communication facilities are so advanced that you cannot say you could not do it. For HR, communication of your delivery is very important; they can even hold your maternity salary for want of this communication. This is because maternity leave of 84 days is applicable only in the case of delivery, and had it been otherwise, they could restrict it to 6 weeks.

Formalities with Mediclaim Service Providers

I am not sure about the formalities regarding communication to the mediclaim service providers, but it should be interpreted that they cannot enroll it antedated. However, if the service providers are on good terms, they should do it for the benefit of the claimant and the continuance of business with the establishment you are working for.

I hope somebody who deals with such cases may be able to post a proper reply. Please post it.

Regards,
Madhu.T.K

In my view, the insurance company is justifying the denial of your claim. When there is no contract between you and the insurance company to insure your son for mediclaim, on what grounds will the insurance company pass your claim? You have taken a stand that you could not enroll the name of your son in the mediclaim policy since you were on maternity leave and you resumed your duty on the expiry of maternity leave after the hospitalization of your son. This stand is not sustainable. Even the insurance company requires intimation of hospitalization within a stipulated time. Enrollment of your son's name in the mediclaim policy has no concern with your maternity leave.

As per my knowledge, the mediclaim company is right in not reimbursing you for the hospitalization expenses of your son as he was not under the insurance coverage at the time of treatment. However, you can check with your HR Department about the terms of the contract. Usually, the mediclaim company specifies the time period within which a new addition (newborn baby after birth) has to be added.

If the liaison is good from your end, you may have some chances of reimbursement because usually, the claim bills are to be submitted within 30-45 days from the date of discharge from the hospital. This would be possible only if the mediclaim company can enroll your son in the coverage list effective from 01st Dec'12.

Let's wait for comments from the seniors at Cite HR.

Have a great day ahead!

Regards,
Anshika Sharma

You will have to check the terms and conditions agreement of your company with the insurance providers. Generally, the agreement provides for the insurance coverage of the newborn baby from day 1, provided you inform the insurance providers of the birth within a specified time frame (normally 15 to 30 days from birth, as agreed in the agreement).

In your case, you can write to your HR department and the insurance service providers a letter stating the reason for the delay and request them to reimburse the claim. If you have third-party agents, please write to them explaining the reason for the delay and requesting reimbursement. They have a good rapport with the insurance providers and can be of great help.

Regards,
DS

Yes, the insurance company has the full right to deny the claim as all insurance companies have a time limit of 3-6 months after childbirth within which you need to inform the insurance company about the childbirth in order to get insurance cover for the child.

The only option is that if your company HR has a very good relationship with the insurance company, then the insurance company could agree to process the claim. If the insurance company is not convinced, then there is no other option but to pay the expenses all by yourself. Do ensure to get your son covered by medical insurance immediately to avoid future issues.

All the best.

The mandatory fact for each insurance claim process is that the individual should be enrolled during the period for which the claim has been made. If the individual is not enrolled, then there is no possibility of the insurance provider settling the claim. The only bleak possibility could be if your company's HR has good relations with the insurance provider and can get it done as a rare exception. Again, this is driven by the facts that your company is given a high volume of business, and the claims history is not very high, etc.

I suggest meeting your HR representative and convincing them to persuade the insurance provider to treat your case as a rare exception.

Hope this info helps.

Regards,
Gia