SACHA ADVICE. ACHA ADVISOR.
back arrow Back

Incorrect Deductions for Health Claim

reply Share
04 Jul, 2022 by  Chirag Bogra

Hi All,


In a recent planned hospitalization for kidney stone removal, I had got pre Authorization for the same in advance from my insurance company - ICICI. The estimates shared from the hospital included all the break-up, Surgeon kee, OT fee, Laser Fee etc. The pre-authorization approved the same & mentioned deduction as only consumables & TPA fee.


At the time of the cashless bill settlement, they rejected the laser amount stating it is not included in the policy, which was around 40% of the total bill. Couple of questions -


1. If this was not included, shouldn't they mention it clearly in the pre-auth.

2. I went through the detailed policy document, couldn't find RIRS(Laser) anywhere in the exclusions.


The company is not sharing any explanation. What could be done?

like like
0
Health Insurance
Parents-Health-Insurance

2 Answer

Post
04 Jul, 2022
CEO, Insurance Samadhan

Dear Chirag

This claim need to be paid and you should contest.

As this was planned surgery amd laser was included .

Company can not refuse now .

You can reach us for guidance.

Best wishes

Shailesh Kumar

Insurance Samadhan


like like
0
icon-comment 1 Comments
icon-reply Reply
06 Jul, 2022
Chirag Bogra
like like
0
icon-reply Reply
04 Jul, 2022
connect with advisor

Hi Chirag,


Pre-authorization is just a conditional approval given by the insurance company as a token of acceptance of the cashless request received from the hospital. Usually, it's during the final approval that the insurer gets into the finer details after getting the complete set of documents such as discharge summary, diagnostic reports, indoor case papers (in a few cases), doctor recommendations, procedural details, and final bill, etc.


However, this can not be an excuse for the insurer to deduct such a big component from your total bill especially since you mentioned having checked the policy document. Would suggest you to get the policy fine print / policy wordings which would have the complete details of the terms & conditions applicable.


If there is no specific mention of such a limit in the policy wordings, you have every right to challenge the decision taken by ICICI Lombard & approach their grievance team. Get the final settlement letter from the insurer as complete details of deductions will be specially mentioned in it & then approach the grievance cell.


https://www.icicilombard.com/grievance-redressal


If the response is not satisfactory, you would then have the option to approach the ombudsman.


https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo3157&flag=1


Hope this information helps you...


Best Wishes,

Satish Kumar H


like like
0
icon-comment 2 Comments
icon-reply Reply
06 Jul, 2022
Chirag Bogra
like like
0
icon-reply Reply
07 Jul, 2022
connect with advisor
like like
0
icon-reply Reply

Tired of dealing with call centers!

Get a professional advisor for life!

Rs. 1799

LIFETIME FREE

Lifetime Free

or

Discover the best tips for insurance every week!

Beshak is not regulated by the Insurance Regulatory and Development Authority of India (IRDAI) and does not have any alliance or association with any Insurance business.
© Copyright 2022 Beshak Solutions Pvt. Ltd. All Rights Reserved.

Disclaimer: The content on the website is purely for information purposes for the public at large, and does not constitute personal financial advice for a specific individual reader.
If you are reading this, it means you love reading the fine print. Why not get paid for what you love doing - Join us by writing to info@beshak.org now 🙂