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Post hospitalisation cover for 60 days but insurer says only 15 physio sessions payable

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11 Jan, 2023 by  Shobhit Tayal

I have care health insurance plan, they covered my hospitalisation expense for ACL Surgery (although they denied citing waiting period at first but it was just a was to delay the payout, later accepted their mistake here)


Now I have submitted post hospitalisation bills for physiotherapy- I underwent 45 sessions till 60th day of discharge from hospital but while paying out they mentioned only 15 sessions are payable.


Unable to find any such clause in the policy wordings or TnC. Can someone help if they can cite that as a valid reason to refuse settlement?

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13 Jan, 2023
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Hi,


The deduction should be based on something called 'Only Reasonable and Customary charges are payable'. If the doctor has prescribed 45 sessions / up to 60 days of physiotherapy, then you can raise a complaint with the grievance dept. of the insurer stating the same. Most likely they won't budge. If you receive a negative response, then raise a complaint with the insurance ombudsman. Although this is a lengthy process, I hope you receive your deserving claim amount.


Thank you

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13 Jan, 2023
Shobhit Tayal
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13 Jan, 2023
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