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Hi :

Looking at it from the hospital perspective, I think since you said you are covered under Insurance the hospital royally escalated the bill for 1 day hospitalisation. Frankly I wonder what kind of tests did they conduct which ran up your bill so high. Secondly they also suggested you to stay 1 day just bcoz you were having insurance coverage.

From the Insurance perspective, most of the service providers do have their inhouse team of doctors who study the reports which is sent to them for claim settlement. They know what would be the approx cost for the tests and if the tests were required at all or not considering the line of treatment and diagnosis. Well though they too try to minimize the claim settlement by stating flimsy reason.

Anyhow I would suggest if you have been covered under Group Medical Insurance through the company, please inform the HR about the rejection of the claim. The HR intervention will help provided your insurance claim meets all the stated norms laid down by the Health Insurance company. Sometimes if the Insurance company wants to maintain service levels inorder to get future renewal from the company they make exceptions and settle the claims.

Meanwhile I think you should take it up with hospital also and question them about the charges they have levied. In a worst case scenario if you have to pay up the bill personally then it is a fairly high amount for a single day hospitalisation for no treatment per se

Hope the above inputs is useful.

- Gia

Hello Muqtadir,

Mr. Gia has a valid point. Insurance companies doctors do certify the necessity and genuineness of the claim or hospitalisation besides its cost.

In your case, even they would have judged the Doctor let you stay in hospital merely on the basis of your insurance. Another important aspect is, your doctor carried out some tests but did not give any surgical treatment. I know, there are some treatments wherein 24 hr. hospitalisation is not mandatory but the use of surgical weapons is a must to qualify them as Day care treatment. In your case it was not a Day care treatment too.

It would have been helpful if you had contacted your HR and he in turn your TPA or Insurance company to find out admissibility of the claim. We follow the same procedure in our organisation. Even the claim documents are submitted by HR and not directly by employee in reimbursement cases.

In Cashless claims, the hospital applies TPA for pre-authorization within 24 hrs. of admission. TPA verifies the applicability of the claim and issues pre-authorization to the hospital and then further process happens. In such cases also, HR is kept in a loop.

I would suggest contact your HR and verify all information w.r.t. your claim and then only decide if to approach court in the matter.

Best regards,

Vaishalee Parkhi

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