Disability evaluation
Mediclaim
Cashless claim denial
Disability evaluation Paavani & Associates help interpret various insurance clauses, fill out related forms, represent you in various stages of Hospitalization. more
Life Insurance
Disability evaluation
Disability evaluation We are experts in the field of Forensic Medicine that have come together to help various agencies in solving complicated issues related to claims. more
General Insurance and Disability
Disability evaluation
Disability evaluation We provide all kind of expertise and consultation related to different policies and provide logical solutions in the settlement of genuine claims. more
Services
Disability evaluation

Mediclaim Procedure


Disability evaluation

1.   The patient(claimant) can get admitted in the hospital on the basis of an:

  • Emergency
  • Non emergency(elective)

2.  Admission

  • If a claimant opts for cashless admission then the entire procedure is done by the hospital administration department (TPA cell in some corporate hospitals). Cashless admission does not mean that you don’t have to pay any amount in the hospital. Some amounts are not admissible by your insurance company for which you have to pay to the hospital over and above amount sanctioned by TPA (third party administrator).

  • If claimant opts for Reimbursement admission then, the entire procedure must be done either by you or your concerned agent. Even in reimbursement claims, some amounts are not admissible by your insurance company for which you have to pay to the hospital.

Mediclaim Documentation

Disability evaluation
  • 1.  Documentation at the time of admission

  • Individual insured-Photo Identity card, TPA card, Policy copies.
  • Corporate insured- Photo Identity card, TPA card, Policy copies, Employee no.

  • After the Pre Authorization form is sent to the respective TPA an amount is sanctioned by TPA. The sanctioning of the amount does not necessarily guarantee your admission. The TPA doctor can visit the hospital and confirm the admission. If the TPA doctor deems fit that, admission is required then sanctioned amount is confirmed. The TPA will sanction the entire claim amount at the time of discharge (except for non payable items, of course).

2.  If claimant opts for Reimbursement admission

  • The claimant (patient) or the agent offers information about the admission to the TPA within 24 hours of admission.
  • The TPA doctor will probably then visit the hospital and confirm the admission. After discharge the claim papers should be submitted within 7 days to the respective TPA either yourself or through the company agent.

Mediclaim Rejection

Cashless claim denial


1. What to do if claim is rejected?

The claim can be rejected in both cashless and reimbursement claims. Rejection can be due to following reasons :

  • On technical ground based on some exclusion clause of the mediclaim policy.
  • Improper documentation
  • Suspicion of fraudulence or false claims

2. In the case of a rejection - representations can be made to the TPA with supporting papers and or certificate or letters from treating doctors. If the TPA rejects the claim twice you can approach the divisional office through which your policy was issued. If the divisional office also rejects your claim then you can approach the Insurance Ombudsman of your State.

3. The Ombudsman is a quasi-judicial body headed by a retired insurance officer where your grievance is heard judiciously. If the claim is rejected by the Ombudsman as well, you can approach Consumer courts.

Life Insurance Claims

Cashless claim denial




For the first time in the city of Mumbai, experts in the field of Forensic Medicine have come together to help various agencies in solving complicated issues related to claims.

    Insurance and Disability claims

    Cashless claim denial
    • Our team of doctors is well versed with various clauses and their interpretations in various policies related to health and life of the insured. We provide all kind of expertise related to different policies and provide logical solutions in the settlement of genuine claims. Evaluation of disability is a complex procedure. Many a times the treating doctor gives disability certificate which may not be concordant with the accepted disability manual or norms. Insurance companies may not accept the certificate and can advise company panel doctors to physically evaluate the claimant. The evaluation results may not match with the treating-doctors certificate which often leads to grievance and hardships and unnecessary delays in claiming one’s settlement.

    • We provide specialized servicing of physical evaluation through subject experts and certifying disability based on disability manuals and accepted norms. This certificate can be used in challenging company doctor’s evaluation at Motor tribunals, Industrial tribunals and any court of law.

    Various Services Offered

    Cashless claim denial

    Mediclaim, Personal Accident Policy & Workman’s Compensation Policy

    • To interpret various insurance clauses of health related policies, personal accident, and workman’s compensation or life insurance policies
    • To fill out all the various and necessary claim forms related to health related policies or life insurance policies
    • To represent you at the crucial pre-authorization stage– in the case of cashless admission non acceptance (in case of mediclaim policies)
    • To represent you at the TPA/Divisional office/ Grievance department of Regional office in the case of the rejection of a genuine claim
    • To represent you at the Ombudsman/Consumer courts or any legal forum (through lawyers) in the case of the rejection of a genuine claim
    • Disability evaluation in case of personal accident, workman’s compensation or life insurance rider policies

    • Life Insurance Claims

    • Opining on various documents related to the Life Insurance claim
    • Opining and interpreting various reports submitted by the claimant

    1. Opining on various documents related to the Life Insurance Claims

    • In any claim related to Life insurance following documents are to be submitted depending on the manner of death, which can be either Natural or Unnatural. In Natural deaths the claimant submits Death Certificate along with clinical papers. In Unnatural Deaths, which can be either Accidental, Homicidal or Suicidal following documents are submitted:
    • Accidental Death Report (ADR)- prepared by the police
    • Panchanama of the scene of Occurrence/ Crime Scene
    • Panchanama of the Dead Body
    • Eyewitness report (Jawab)
    • Clinical Papers in case of hospital deaths
    • Postmortem Report
    • Chemical Analyzers reports
    • Histopathology report
    • Other accessory reports

    It is the most difficult task to opine and interpret all these documents particularly in complicated issues related to death and where the documents are manipulated in fraudulent cases.

    Paavani & Associates with their team of forensic experts help to find out the logical solutions in such cases.

    Paavani & Associates will assist to opine on following points in Postmortem report

    A. Column no 17 of Postmortem Report
    Column no 17 of postmortem reports documents lists of injuries, which can be due to various unnatural causes.

    B. Cause of Death
    To Opine on a cause of death and interpreting is a special task Forensic Medicine advisors of Paavani & Associates have conducted around 5000 postmortems in relation to Accidental deaths/ Suicidal Deaths/ Homicidal deaths and have helped investigating agencies solve cases.

    Our Forensic Medicine advisors are also capable of interpreting causes of death and analyzing them in relation to column number 17 of postmortem.

    C. Opine on Manner of Death
    Manner of death can be either accidental or homicidal or suicidal. Forensic Medicine advisors from Paavani & Associates will help you in deciding about the manner of death by using vast experiences and logical theories in deciding any complicated issues in question.

    Click here for more details on Claim Procedures Under Life Insurance

    2. Opining and interpreting various reports

    Paavani & Associate helps claimant’s/ Legal representatives in analyzing; opining & interpreting various reports submitted by the claimant i.e. Chemical analyzers report, Ballistic report, DNA Finger print report, Histopathology report etc submitted in any matter under question.

    3. Defending in any Legal Forums in rejected claims

    Paavani & Associate along with the legal advisors helps claimant’s/ Legal representatives in defending their cases in any Legal forum like Ombudsman, Consumer Court or any other Civil Court in any matter under question.

    Service Charges

    Sr. No.
      Details of Consultation   Amount(In Rupees)
    1
      Consultation before accepting the case   500
    2
      Routine Scrutiny of file with opinion on Mediclaim/ any other health related policy/Life policy Matters without any specialists opinion   1000
    3
      Scrutiny of file with Specialist opinion on Life Insurance Matters   2000
    4
      Critical Analysis of the Postmortem report, Inquest Panchanama and any other document made available, to make the evidence of the doctors who has performed the postmortem invalid in LIC Matters   5000
    5
      To comment on the available photographs and extract favorable deductions to support our theory   50/ Photograph
    6
      To answer only queries in claims related to Life policy matters(after case is accepted)   800
    7
      Disability Evaluation by a Orthopaedic Surgeon or opinion on Files of disability   2000/- per case
    8
      To attend Ombudsman for any matter related to Mediclaim/ any other health related policy/Life policy Matters in which our Opinion is sought   5000/- per case + travelling expenses
    9
      Defending in any other Courts   Lawyers fees(depending on the case) + Doctors opinion fees + Travelling expenses and miscellaneous expenses(in package)
    Note:

    The charge does not include service tax. The invoice will be raised on case-to-case basis and service tax of additional 12.36% will be added on the charges mentioned in each column. The said charges are subjected to revision as and when the firm decides after mutual discussion.