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Claim from an excluded provider/hospital

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16 Aug, 2021 by  Avinash Sonee

Generally in health insurance policies, it is mentioned that


Excluded Providers - Code Excl 11: Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.


Few questions related to the above clause


  1. Is the list of excluded providers common across all health insurance companies and plans?
  2. What if the customer or the patient's attender is unaware of this clause or have forgotten about it while getting admitted into the hospital? Is there any consideration given if the emergency admission is proven which is subjective.
  3. How does a customer prove the life threatening situation? and the stage of stabilization? Does it have to be certified by a third party doctor not affiliated to the said hospital?
  4. Given the covid situation, can the customer claim that this was the only hospital where he could find a bed? How can this be proved/verified?
  5. anything else which can lead to claim approval or rejection?


Thank you

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21 Aug, 2021

Dear Avinash

Insurance companies black list hospitals and medical practices on evidence of malpractices which causes harm to insurance principle.

Answers are given below

1. No , it is not common . All insurer make their own list .it is duty of insurer to regularly update their policy holders .

2. It is duty of policy holders to inform the insurer about admission immediately. Insurer company would confirm the status of exclusion and would refuse to entertain . Policy holder need to take corrective action .

3. No , the diagnosis would determine the life threatening situation . For example , in case of cardiac arrest , the first aid can be taken in excluded provider and shift to a network hospital .


4. Insurer would refuse to entertain such admission . Pl note that hospital is black listed due to mal practice and insurance company have informed policy holder .

5.

.

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The reason for this exclusion in my view is to discourage the insured from taking treatment at blacklisted hospitals or facilities that are known to falsify bills or engage in fraudulent activities. The applicability of the exclusion should be seen in that context and should not be read in isolation. The list of such hospitals need not be common across all insurers, eventhough there can be commonality.


If the insured has gone to such a hospital for treatment, the insurer has to make a judgment on the circumstances under which such treatment became necessary, whether it was an emergency involving a life threatening condition and that other hospital options were not available at the time.


I would expect the insurer to take a holistic view depending on circumstances of each case and not based on any set rules.



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21 Aug, 2021

contnd

5. Request can be made through active line of treatment which is reasonable and justified. Insurer may consider .


Please note that insurance company do not take an arbitrary decision on exclusion but on basis of multiple reports and evidences. So we shall have to check with intent and help industry to function for public interest.

Insuramce will not be able to function if such wrong practices are not curbed .


Shailesh

Insursnce Samadhan

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21 Aug, 2021
Avinash Sonee

Thank you for answers. Will update the forum on the claim status after it is processed.

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