Customary and reasonable satisfactory charges in network hospitals
I have a Sbi arogya premier policy it covers maternity with no sub limit but with customary and reasonable satisfactory charges clause, my question does this apply in cashless claim in network hospital ? As in network hospital mou rates are pre agreed !!
Let me explain you what's customary and reasonable satisfactory charges as per the policy.
This clause in short tell you that just because you have health insurance you can't overspend for a particular treatment.
You need to be aware about the costs of the nearby hospitals in the locality/region before getting admitted and basically limits you to avail expensive treatment if same is available for a lower charge at some other hospital nearby.
The clause will be applicable for both reimbursement and cashless.
Thank you for your reply.
i have even asked this to the Tpa and they have replied me as such
In case of cashless we will process as per agreed tariff with the hospital for reimbursement claim customer reasonable clause will be apply for MOU rates please coordinate with hospital.
i feel still there is scope of confusion and self interpretation is there, what is your take on this answer ??
Customary & Reasonable charge clause means a fair charge charged for a particular treatment in specific region. If hospital is charging exaggerated charges than what is running in your nearby region than this clause will be applicable to Reimbursement Claim as well as Cashless Claims Too.
So you just need to be proactive and find out the charges for a particular treatment in your nearby hospital so that you cannot be a victim of this Reasonable & Customary Charge Clause.
there is no same category hospital near me let’s say in the range of 7 km radius.
what else should I do in such case ?
This is subject to debate.
Do talk to your TPA and they may give you some clarity as well
It's also always recommended to go for policies which have fewer sub limits if budget is not the constraint, because that way you know you'll be reimbursed in full and you'll have one less thing to worry about while getting hospitalised and you'll not have to compromise with the best treatment.
Reasonable and Customary charges has been the most debated condition of mediclaim policy. Insurer do deduct on this basis if they find the spending as exorbitant vis-a-vis amount charged by another hospital in same geographical area for the same procedure, however, many a times they also take the advantage of this condition to do unfair deductions.
In my opinion,in this case the insurer has not done the right thing by imposing Reasonable and Customary condition on maternity claims. Most insurers fix a sub-limit for procedures like maternity and cataract which makes the treatment of claim very clear.
Not to forget, onus of proving the Reasonable and Customary deduction is always on the insurer and most times,if challenged in ombudsman or consumer court, claimant wins. That is the precise reason why most insurers are removing this Reasonable and Customary condition from their policies now. The case of insurer is even more weak if these deductions are done by a network hospital.
Suggestion-If you are yet to claim then discuss with TPA/Hospital/Insurer to avoid any complication regarding the interpretation. If you have already claimed and deduction has been done, lodge a protest with the insurer.
Thank you for your reply.
i have asked this to the Tpa and they have replied me as such
“In case of cashless we will process as per agreed tariff with the hospital, for reimbursement claim customer reasonable clause will be apply.”
can you please give your opinion on this. ?
The customary & reasonable charges cannot be applied in case of cashless claim since the rate decided with network hospital are already predecided rates based on the MOU signed with the Hospital by the insurance companies.
Here it can be noted that if there is an ailment capping then the claim will be processed based on the sublimit even though the agreed rates may be higher than the sublimit.
The customary and reasonable charges are applied on reimbursement claim and incase if the insured has opted reimbursement claim in network hospital then the claim will be processed on the agreed rates and balance amount will have to be borne by the insured.