Dinesh Divekar
Business Mentor, Consultant And Trainer
Pon1965
Construction
Vaishalee Parkhi
Hr Consultant & Trainer
Radhika.ashokanand
Soft Skills Training
+5 Others

Thread Started by #muqtadira786

Dear Seniors,

I have Health Insurance from my company. Actually am suffering from Dizziness and slurring of speech. I had admitted in the Hospital in an emergency due to panic attack and dizziness, people took me to the emergency ward. Immediately doctor had taken MRI and some blood test but found normal. So at the time of releasing from the hospital Doctor told me to stay for one day because i have an Insurance. Actually he wanted to thoroughly check, why it is happening like that.

I stayed for 24 hrs in the hospital, but Doctor didn't do any surgery. Just they did all checkups and given some tablets but found normal.

Now the insurance company is denying to approve my claim as the hospital's officials charged around Rs.37443/-, because they didn't do any treatment or surgery. But they did checkups to find out the disease.

I took this concern to the Hospital's higher officials, but he is saying that Insurance company should approve your claim. All these checkups come under treatment only. If they are denying to approve then take this issue to the consumer court.

Please help me what should i tell them to get back my amount from the insurance company.

Thanks & Regards,

S.A.Muqtadir

SAN Engineer
10th June 2013 From India, Hyderabad
Dear Muqtadir,

Insurance claims are processed for the hospitalisation arising out of to some disease. Therefore, what matters is what diagnosis that doctors have written in the medical certificate. Is that disease covered under the insurance?

Secondly, when you admitted, why you did not use your cashless card (issued by the health by insurance companies)? Sooner you got admitted did you inform the insurance authorities? This is because sooner they receive information of admission, they visit the hospital and verify the authenticity of the admission. Above all is that hospital (where you were admitted) "approved" by the health insurance company?

Go to the office of health insurance company and talk to them. Find out why the health insurance claim was turned down. Find out will they accept any fresh medical certificate.

The last resort is to file complaint in "Consumer Forum". However, before that I recommend you reading thoroughly the conditions under which health insurance claims are processed. Find out whether they are contradicting.

Ok...

Dinesh V Divekar
10th June 2013 From India, Bangalore
In case still no luck please log a complaint of IRADA. Rohit
10th June 2013 From India, New Delhi
Dear Dinesh,

Thanks for your reply.

Yes, this disease covered under cashless facility because i fell down on road while going to home from the office in the evening. I had admitted in the Care Hospital Banjara Hills here in Hyderabad on 30th May and discharged on 1st of June. Yes, this Hospital come under Network facility and it is approved by the Insurance company, that's why they had admitted in the Hospital because i have insurance. I

I think when i admitted, the Hospital's people didn't send any mail to Insurance company regarding me, because i had admitted in the eve around 8.15PM.

Apart from that when i admitted in the Hospital, immediately Doctors asked me if you have insurance then submit initials to the Insurance counter before that they didn't even start any treatment. So, i had shown them TPA-Mediassist card which i got from the ICICI LOMBARD insurance company and same i submitted it to the insurance counter, after submitting the photo copy of insurance card then only they started doing treatment.

Whether should i speak to my HR regarding this issue or not required.

Ok, i will do as you said, will go and check from the Insurance company.

Thanks once again !!!
11th June 2013 From India, Hyderabad
Hi Muqtadir, It is a good idea to keep your HR informed. If you request your HR, they will check with the Insurer and sort things out. May you get well soon! Cheers! Radhika
12th June 2013 From India, Madras
Dear Muqtadir,
In this case you may send a mail to HR dept and explain all this circumstances clearly so that they do co-ordinate with insurance person and help you out.
Also get a clear discharge summary with your case history from your admitted hospital .
Thanks and Regards
Laxmi
Senior Executive - HR
12th June 2013 From India, Madras
Hi,
Is this a group policy taken by your organisation for all the employees?
Than i would suggest your take guidance and check with your admin who is one point contact handling insurance queries in the organisation and maybe ask him to speak to the insurance agent as why the same is not getting cleared.
12th June 2013 From India, Mumbai
Dear S.A.Muqtadir
First of all you know one thing Mediclaim health insurance is claim is payable only in required of 24 hours hospitalization with necessity.
In your case there is no necessity to admit in INPATIENT CARE it takes in out patient care thats only your claim rejected.
In a view of your wordings only medical tests only taken there is no scope of treatment. In my view the claim is not Payable.
May be your TPA is correct.
this is not valid claim to prove in Grievance , Ombudsman.IRDA.
Dont waste your Time. after discharge you should mention your doctor to prescribed clearly in Discharge summary.
Thanks & Regards
S.Vinoth Kumar
12th June 2013 From Czech Republic, Prague
Your case is not coming under hospitalization but OP treatment. That’s why Insurance companies turned down your claim. Normally, they approve the claim for hospitalisation. Pon
12th June 2013 From India, Lucknow
Dear PON195
OP treatment s are not payble in insurance companies (Op treatment payable under dog, snake bite only some PVT insurance co have OP treatment payable under some conditions) in this case claim is not Payable
Thanks & Regards
S.Vinoth Kumar
12th June 2013 From Czech Republic, Prague
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
12th June 2013 From India, Pune
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
12th June 2013 From India, Pune
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