Bank Employees Complain as TPA Companies Reject Health Insurance Claims on Minor Issues

A very shocking and sensitive issue has come to light regarding the health insurance facility provided to bank employees. According to information received from several bank employees, TPA companies are rejecting health insurance claims on minor grounds. We received an email from a Punjab National Bank (PNB) employee stating that his claim was rejected by the Heritage TPA company. The screenshot of the rejection email is given below.

Let’s understand the whole story. In this case, we will have a look at this case only. The claim has been rejected, citing three reasons. The Heritage TPA company rejected the claim, saying:

1. GST number of medical shop is not valid.
2. Original USG Feto profile report.
3. Date of Discharge is mismatch.

After reviewing the case and documents submitted by the bank employee to Heritage TPA, it was found that the employee had filed a claim for reimbursement of expenses incurred during his wife’s delivery operation. The employee submitted all the required documents to the TPA company. When we looked into the three points raised by the TPA company, we found:

1. The GST number of the medical (pharmacy) shop was not mentioned on the bills. These bills were for medicines purchased from the pharmacy. The TPA company demanded the GST number of the shop. If the GST number was not mentioned on the bills, the company could have called the employee or the hospital to obtain it. However, the company did not contact the employee and rejected the claim over this minor issue.
2. The TPA company demanded the original USG Feto Profile report. A USG Feto Profile Report is a medical ultrasound report used during pregnancy to check the health and well-being of the baby inside the womb. However, if the doctor has already mentioned in her report that the woman needed to undergo an operation due to complications, and the discharge summary also confirms the treatment, then what is the point of demanding the USG Feto Profile report? Even if the company required the report, it could have simply called or emailed the employee, and the employee could have easily provided it.
3. The third point raised was a mismatch in the date of discharge. In the hospital discharge bill, the date was mentioned as 02.01.2026, while in the discharge letter it was written as 02.01.2025. The patient was admitted on 30.12.2025 and the new year had just begun, so this clearly appears to be a typing mistake. All the computer-generated bills and documents had the correct date mentioned. Only in one manual document, the year was written as 2025 instead of 2026. Is this really such a big mistake? It is common for people to type the wrong year in the beginning of a new year. Rejecting a claim for such a minor error seems unreasonable.

Also Read: How to download Bank Heritage TPA Health Insurance Card?

Thus, we believe that all the points raised by Heritage TPA are baseless. These issues could have easily been resolved through a simple email or phone call. However, the company neither emailed nor called the employee. Instead, the claim was rejected and all the documents were returned via courier. Banks pay premiums to insurance companies to provide health insurance facilities for their employees. Now, employees are demanding that banks remove third-party TPA companies and deal directly with insurance companies.

A TPA is a company that manages health insurance claims and services on behalf of an insurance company or employer. They act as a middle agency between the insurance company, the hospital, and the insured person.

Employees are not happy with the services of TPA companies. This case is just one example of how claims are being rejected. A claim that could have been settled with a simple phone call was delayed and eventually rejected citing minor issues. Another concern raised by employees is why TPA companies demand original documents. They could simply accept self-attested documents instead.

TPA companies should avoid demanding original hospital documents from patients while processing insurance claims. Medical records such as discharge summaries, prescriptions, diagnostic reports, and hospital bills are very important for patients, as they may be required for future treatment, medical history, or other insurance and legal purposes. If these original documents are submitted to the TPA, patients often lose access to their own medical records, and obtaining duplicates from hospitals can be difficult. Instead of collecting original documents, TPAs should accept verified copies, scanned documents, or digitally submitted records. If necessary, they can verify the documents directly with the hospital or temporarily check the originals and return them to the patient. With increasing digitalization in the healthcare and insurance sectors, TPAs should adopt more patient-friendly systems that protect the claimant’s medical records while still ensuring proper verification of claims.

Also Read: How to download Bank Heritage TPA Health Insurance Card?

What are the suggestions for Banks regarding TPA Claim Settlement?

• Remove third-party TPA companies: Banks should consider removing third-party TPA companies and instead create an in-house claim settlement team to handle employees’ health insurance claims.
• Contact employees before rejecting claims: If any document or information is missing, the bank or TPA should call or email the employee and give them time to submit the required documents instead of rejecting the claim immediately.
• Do not demand original documents: Original medical documents should not be taken from employees as they may be required for future treatment, medical records, or other claims. Verified copies or digital documents should be accepted.
• Allow time to correct minor mistakes: If there are small errors such as typing mistakes, missing GST number, or date mismatch, employees should be given an opportunity to correct them.
• Provide clear claim guidelines: Banks and insurance companies should provide clear instructions and a checklist of required documents so that employees know exactly what to submit.
• Create an online claim tracking system: Employees should be able to track the status of their claims online to know whether the claim is under review, approved, or if any document is required.
• Fix a time limit for claim processing: Claims should be processed within a fixed time frame so that employees do not face unnecessary delays.
• Improve grievance redressal system: A proper complaint or grievance mechanism should be created where employees can raise issues if their claims are unfairly rejected.
• Direct coordination with hospitals: TPAs or insurance companies should verify bills directly with hospitals instead of rejecting claims due to minor documentation issues.
• Regular review of TPA performance: Banks should regularly review the performance of TPA companies and take action if employees repeatedly face problems in claim settlement.

Also Read: How to download Bank Heritage TPA Health Insurance Card?