Incorrect Deductions for Health Claim

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?

Health Insurance

Parents-Health-Insurance

2 Answer

Post

04 Jul, 2022

Shailesh Kumar

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

1 Comments

06 Jul, 2022

Chirag Bogra

Thanks for details. Since the claim was through TPA & TPA is not giving any response on the matter - can this be directly taken up with insurer?

04 Jul, 2022

Satish Kumar

4.4

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

2 Comments

06 Jul, 2022

Chirag Bogra

Thanks for the details. Since the pre-auth was based on itemized bill estimate which clearly specified laser charges - is insurer within it's rights to first approve in pre-auth & then finally deny? Since the claim was through TPA, can this directly taken up with the insurer?

07 Jul, 2022

Satish Kumar

4.4

Hi Chirag,

You must in this case approach the grievance redressal team of ICICI Lombard immediately. A TPA is just an intermediary between the insurance company and the policyholder and only provides operational services such as claims processing and employee benefits management for corporate accounts.

Disputes with respect to claim repudiation or incomplete settlements should be taken up directly with the Insurance Company.

You have the right to challenge the decision & if you fail to receive a satisfactory reply from the insurer please take the help of Insurance Samadhan.

Best Wishes,

Satish Kumar H

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