How Can I Get My Insurance to Cover Hospital Bills for Emergency Checkups?

Dear Seniors,

I have health insurance from my company. Actually, I am suffering from dizziness and slurring of speech. I was admitted to the hospital in an emergency due to a panic attack and dizziness; people took me to the emergency ward. Immediately, the doctor took an MRI and some blood tests but found everything normal. So, at the time of release from the hospital, the doctor told me to stay for one day because I have insurance. Actually, he wanted to thoroughly check why it is happening like that.

I stayed for 24 hours in the hospital, but the doctor didn't perform any surgery. They just did all the checkups and gave me some tablets but found everything normal.

Now the insurance company is denying approval of my claim as the hospital's officials charged around Rs. 37,443/- because they didn't perform any treatment or surgery. However, they did checkups to find out the disease.

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

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

Thanks & Regards,

S.A. Muqtadir

SAN Engineer

Insurance Claims and Hospitalization

Insurance claims are processed for hospitalization arising from a disease. Therefore, what matters is the diagnosis that doctors have written in the medical certificate. Is that disease covered under the insurance?

Secondly, when you were admitted, why did you not use your cashless card (issued by the health insurance companies)? Did you inform the insurance authorities soon after admission? It is important to inform them promptly as they visit the hospital to verify the authenticity of the admission once they receive the information. Moreover, is the hospital you were admitted to "approved" by the health insurance company?

I recommend visiting the office of the health insurance company to discuss the reasons why the health insurance claim was rejected. Inquire whether they would accept a fresh medical certificate.

As a last resort, consider filing a complaint with the "Consumer Forum." However, before taking this step, I suggest thoroughly reviewing the conditions under which health insurance claims are processed to check for any contradictions.

Regards,
Dinesh V Divekar

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

I think when I was admitted, the hospital's staff didn't send any mail to the insurance company regarding me, as I was admitted in the evening around 8:15 PM.

Apart from that, when I was admitted to the hospital, the doctors immediately asked me if I had insurance and instructed me to submit my details to the insurance counter before any treatment could begin. So, I showed them my TPA-Mediassist card, which I received from ICICI LOMBARD insurance company, and submitted it to the insurance counter. Only after submitting a photocopy of the insurance card did they start the treatment.

Should I speak to my HR regarding this issue, or is it not required?

Okay, I will do as you said and go and check with the insurance company.

Thanks once again!

Best regards,
Muqtadir

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

In this case, you may send an email to the HR department and explain all these circumstances clearly so that they can coordinate with the insurance person and help you out. Also, make sure to obtain a clear discharge summary with your case history from the hospital where you were admitted.

Thanks and Regards,
Laxmi
Senior Executive - HR

Is this a group policy taken by your organization for all the employees? Then I would suggest you seek guidance and check with your admin, who is the point of contact handling insurance queries in the organization. Perhaps ask them to speak to the insurance agent to inquire why the same is not getting cleared.

Dear S.A. Muqtadir,

First of all, you should know that Mediclaim health insurance is payable only in the case of required 24-hour hospitalization with necessity. In your case, there is no necessity for admission in INPATIENT CARE; it falls under outpatient care, which is why your claim was rejected.

From your explanation, it seems that only medical tests were conducted with no actual treatment provided. In my opinion, the claim is not payable. Your Third Party Administrator (TPA) may have the correct information.

This claim may not be valid to prove in a Grievance with the Ombudsman or IRDA. It would be best not to spend more time on this. After discharge, ensure that your doctor clearly prescribes the treatment in the Discharge summary.

Thanks & Regards,
S. Vinoth Kumar

Understanding Insurance Claim Rejection

Your case is not classified under hospitalization but as outpatient (OP) treatment. That's why insurance companies have rejected your claim. Typically, they approve claims for hospitalization.

Regards,
Pon

OP treatments are not payable in insurance companies. OP treatment is only payable under specific conditions such as dog or snake bites, and only some private insurance companies have OP treatment payable under certain circumstances. In this case, the claim is not payable.

Thanks & Regards,
S. Vinoth Kumar

Looking at it from the hospital perspective, I think since you said you are covered under insurance, the hospital royally escalated the bill for one-day hospitalization. Frankly, I wonder what kind of tests they conducted that ran up your bill so high. Secondly, they also suggested you stay for one day just because you had insurance coverage.

From the insurance perspective, most service providers have their in-house team of doctors who study the reports sent to them for claim settlement. They know the approximate cost for the tests and whether the tests were necessary, considering the treatment and diagnosis. Although they also try to minimize claim settlements by stating flimsy reasons.

I would suggest that if you are covered under group medical insurance through the company, please inform HR about the rejection of the claim. HR intervention can help if your insurance claim meets all the norms laid down by the health insurance company. Sometimes, if the insurance company wants to maintain service levels to secure future renewals from the company, they make exceptions and settle claims.

Meanwhile, I think you should also take it up with the hospital and question them about the charges they have levied. In a worst-case scenario, if you have to pay the bill personally, it is a fairly high amount for a single day of hospitalization without treatment per se.

I hope the above input is useful.

Regards, Gia

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

In your case, even they would have judged the doctor letting you stay in the hospital merely on the basis of your insurance. Another important aspect is, your doctor carried out some tests but did not provide any surgical treatment. I know there are some treatments wherein 24-hour hospitalization is not mandatory, but the use of surgical procedures is essential to qualify them as daycare treatment. In your case, it was not a daycare treatment either.

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

In cashless claims, the hospital applies to the TPA for pre-authorization within 24 hours of admission. TPA verifies the applicability of the claim and issues pre-authorization to the hospital, and then further processing occurs. In such cases also, HR is kept in the loop.

I would suggest contacting your HR and verifying all information regarding your claim and then only deciding whether to approach the court in the matter.

Regards,
Vaishalee Parkhi