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Cataract Surgery - Urgent Help

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Budhe-Baba

Friend has a corporate policy with Paramount TPA.

His father needs to have cataract surgery tomorrow (day care). Total cost is 55k for 1 eye (25k surgery, 25k lens cost). He called TPA who said that there is no cap/limit on this surgery.

But when he called hospital, they said they have some MOU/Agreement with TPA that only upto 30k will be paid by TPA in cashless mode. So he will have to pay 55-30k from pocket.

Is that how it usually is? Cashless mode has limits? What should he do?

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Deal Cadet Deal Cadet
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Even if he goes with remburisment way there will be same cap so better check the policy terms and condition once

Deal Cadet Deal Cadet
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Also why so much high price 55k even in mumbai its costing around 25-35k only at well reputed doctor

Deal Subedar Deal Subedar
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55K for cataract surgery ? what kind of loot is going on …. In my city reputated doctors do it for 12-15 K , even cheaper if some contacts used .

Once again seeing this healthcare / insurance / cashless jumla , everyone trying to make money this way or other way .

Deal Newbie Deal Newbie
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PPN Rate Hospital has agreed with TPA/ Insurance Companies is probably 30K for catract surgery. However they plan on charging higher than PPN rate ie 55K and asking you to foot the remaining bill. Kindly contact TPA. If the hospital is not agreeing then choose a different one.

Deal Subedar Deal Subedar
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55k is too much, you can first check with doctor what kind of lens he is using, you will have option to choose from them,
you can go with 30k lens so that its all covered.
ALSO check the policy documents for the exact limits it will be mentioned per eye
@drjpatwa

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baadshah wrote:

55k is too much, you can first check with doctor what kind of lens he is using, you will have option to choose from them,
you can go with 30k lens so that its all covered.
ALSO check the policy documents for the exact limits it will be mentioned per eye
@drjpatwa

27k for toric lens and 25k for surgery. Total 55k

Policy document says no limit, but Hospital is saying that TPA will not pay more than 30k for cashless. Strange.

Deal Subedar Deal Subedar
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You still have time to decide the lens.
Not sure if you wish to delay this for 1-2 day if money factor
.
Also this is excluded from hospitalization admission, I guess day care means the same
By the way who is the doctor.

Mobile Guru Mobile Guru
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saymyname78 wrote:

55K for cataract surgery ? what kind of loot is going on …. In my city reputated doctors do it for 12-15 K , even cheaper if some contacts used .

Once again seeing this healthcare / insurance / cashless jumla , everyone trying to make money this way or other way .

I got cataracts somehow and was even willing to spend 1L or 2L.
The Blade less surgery itself costs ~1L. They do start with 20k and continue quoting upto 1L or more based on the technique used and the lens, if money is not a constraint people usually tend to pick the costliest option with the assumption it yields best results

I was ready for everything but the doc said this after examining my case " Delay as long as possible if the symptoms are minute. This won’t get worse with me unlike other cases & surgery might make things complicated for you than they are now "

Deal Subedar Deal Subedar
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saymyname78 wrote:

55K for cataract surgery ? what kind of loot is going on …. In my city reputated doctors do it for 12-15 K , even cheaper if some contacts used .

Once again seeing this healthcare / insurance / cashless jumla , everyone trying to make money this way or other way .

Hospitals are for loot only. As soon as you say I have “Insurance from company”, hospitals inflate price for same surgery to double-triple in such a way that they can get money from your pocket too along with payment from insurance company.

E.g. I have done my father cataract surgery just few months ago and they asked for ~40k and later when I pushed and used some contacts, for exactly same surgery and lens they charged 25K as I have insurance cover upto 25k. If insurance cover is 30k or 20k, then price of same surgery would also be adjusted accordingly.

In civil hospital, cataract surgery is just for 5rs, but we cannot trust civil hospital services and ready to pay higher price at private hospital…

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dealyogi wrote:

Hospitals are for loot only. As soon as you say I have “Insurance from company”, hospitals inflate price for same surgery to double-triple in such a way that they can get money from your pocket too along with payment from insurance company.

E.g. I have done my father cataract surgery just few months ago and they asked for ~40k and later when I pushed and used some contacts, for exactly same surgery and lens they charged 25K as I have insurance cover upto 25k. If insurance cover is 30k or 20k, then price of same surgery would also be adjusted accordingly.

In civil hospital, cataract surgery is just for 5rs, but we cannot trust civil hospital services and ready to pay higher price at private hospital…

My corporate insurance is upto 3L (25% copay) and the cataract surgery cost quoted was ~55k (27k lens, 25k surgery), but the point is hospital says only upto 30k will be processed by TPA.

Deal Subedar Deal Subedar
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Budhe-Baba wrote:

My corporate insurance is upto 3L (25% copay) and the cataract surgery cost quoted was ~55k (27k lens, 25k surgery), but the point is hospital says only upto 30k will be processed by TPA.

Bro, my cooperate insurance is also 3L-4L (I dont remember exactly), but there is cap for specific diseases/surgery, e.g. for cataract maximum is 25k (10% copay) per eye. So even if your cover is 3L, still I suggest to read your insurance policy, there would be some cap on cataract surgery per eye. Also there is no separate category like “Surgery+Lens”, its total cost comes under cataract (until no hospitalization).

Similarly there is cap on Maternity (Normal and C-section have different cap).

You might find similar lines as below in your policy.
https://cdn0.desidime.com/attachments/photos/666466/medium/7400851123.jpg?1613739448

Deal Baba Deal Baba
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yes there is a limit……he has to pay extra amount or opt for the lower one…..and you are saying its a day care and not admitting to hospital

Deal Cadet Deal Cadet
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Your insurance company having the limitations not the hosiptal.

And also don’t do two eyes at a time you may take brake between and apply for two claims

Deal Subedar Deal Subedar
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siva.murala378 wrote:

Your insurance company having the limitations not the hosiptal.

And also don’t do two eyes at a time you may take brake between and apply for two claims

Right. Same I did for my father’s both eyes. 1 eye at a time per financial year, advisable as per health and claim settlement, until its absolutely necessary both eyes at once.

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siva.murala378 wrote:

Your insurance company having the limitations not the hosiptal.

And also don’t do two eyes at a time you may take brake between and apply for two claims

No.

The TPA confirmed there is no cap and we can go for any MONOfocal lens. But the hospital is playing trick. Trick is that the hospital is raising total expense amount as 30k (instead of 55k) saying that that is the standard package. Standard package consists of base monofocal lens whereas we were opting for toric monofocal lens. This toric monofocal lens needs to be paid from own pocket. Why doesnt the hospital raise entire 55k amount and let TPA take the decision of agreeing/denying the claim?

Also, the corporate health insurance policy is just a 10 page PPT with no mention of minute details. @dealyogi

Hunk Hunk
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55k for both eyes or single eye? All right, if both eyes then it is reasonable. For 25k, you might be getting Tecnis monofocal IOL, at least you should be getting it. If your budget is 55k, you should be looking at a decent progressive lens. 25k as medical fee is really exorbitant. But is he opting for laser surgery or traditional phaco technique? Ask him to get an Eyehance lens. Very very decent lens. But everything might be fixed as of now. I will wish him all the best

Entertainer Entertainer
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bikidas2060 wrote:

55k for both eyes or single eye? All right, if both eyes then it is reasonable. For 25k, you might be getting Tecnis monofocal IOL, at least you should be getting it. If your budget is 55k, you should be looking at a decent progressive lens. 25k as medical fee is really exorbitant. But is he opting for laser surgery or traditional phaco technique? Ask him to get an Eyehance lens. Very very decent lens. But everything might be fixed as of now. I will wish him all the best

55k per eye. Manual (non-laser surgery).
Such is the pathetic state of affairs, hospitals doing open fraud.

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Budhe-Baba wrote:

27k for toric lens and 25k for surgery. Total 55k

Policy document says no limit, but Hospital is saying that TPA will not pay more than 30k for cashless. Strange.

Hospitals have negotiated rate lists/MOUs with TPAs. But that doesn’t mean they will charge extra amount to the patient. Minor amount like some consumable costs, PPE Charges etc they are charging separately, thats all.

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saymyname78 wrote:

55K for cataract surgery ? what kind of loot is going on …. In my city reputated doctors do it for 12-15 K , even cheaper if some contacts used .

Once again seeing this healthcare / insurance / cashless jumla , everyone trying to make money this way or other way .

My father underwent a cataract surgery in 2017. Cost was around 80k per eye. (Entire amount Covered by insurance) It all depends on the hospital & lens you are choosing.
Reputed doctors in govt hospitals will do it for free.

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igen wrote:

PPN Rate Hospital has agreed with TPA/ Insurance Companies is probably 30K for catract surgery. However they plan on charging higher than PPN rate ie 55K and asking you to foot the remaining bill. Kindly contact TPA. If the hospital is not agreeing then choose a different one.

Correct.
Bring it to the notice of TPA/Insurance Co. that you are being forced to pay extra amount.

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It is an elective surgery, not an emergency surgery so tell the hospital to file a preauthorisation request with TPA for the 55k amount.
If it is approved, go ahead with 55k surgery.
If not approved, take it up with TPA why they didn’t approve when the policy states no upper cap on discount.
If hospital refuses to file a preauth for 55k surgery then choose a different hospital.

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cm4444 wrote:

It is an elective surgery, not an emergency surgery so tell the hospital to file a preauthorisation request with TPA for the 55k amount.
If it is approved, go ahead with 55k surgery.
If not approved, take it up with TPA why they didn’t approve when the policy states no upper cap on discount.
If hospital refuses to file a preauth for 55k surgery then choose a different hospital.

4th point is happening. Hospital filed a preauth for 30k , not 55k.
Saying standard package charges are 30k (and remaining amount is for higher-quality lens and hence has to be paid from pocket).

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Budhe-Baba wrote:

4th point is happening. Hospital filed a preauth for 30k , not 55k.
Saying standard package charges are 30k (and remaining amount is for higher-quality lens and hence has to be paid from pocket).

Inform that to TPA and NABH (if the hospital in NABH Accredited) and choose another hospital.

Deal Lieutenant Deal Lieutenant
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My mother had eye surgery as her power was -13 . So had to replace the lens with an artificial one.
They gave 3 lens options. 10,20,50k . There are 2 types of surgeries : I don’t remember the details but we chose the better one and it costed 14k. And chose the 50k lens. And yes only the operation cost was given by the insurance not the lens price. So they are partially correct. But operation cost must not be this high. Or they have increased in 3 yrs maybe

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baadshah wrote:

55k is too much, you can first check with doctor what kind of lens he is using, you will have option to choose from them,
you can go with 30k lens so that its all covered.
ALSO check the policy documents for the exact limits it will be mentioned per eye
@drjpatwa

Almost all PSU company’s plan have upper limit of cataract even though it is not mentioned in policy wording. They do it under clause of reasonable & customary clause which differs city to city. In my city they pass around 30k for cataract.

@baadshah Hope this helps….

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drjpatwa wrote:

Almost all PSU company’s plan have upper limit of cataract even though it is not mentioned in policy wording. They do it under clause of reasonable & customary clause which differs city to city. In my city they pass around 30k for cataract.

@baadshah Hope this helps….

edited

Deal Subedar Deal Subedar
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My grandfather had a cataract surgery just before lock down .Total price incl lens was 42k. Entire amt was paid by HDFC ergo via cashless claim .
There was another lens which mimics the human eye I forgot the name , the lens alone costed 80k and surgery 12k. Here Hdfc ergo denied the lens payment and told they will only cover the hospital bills

Deal Subedar Deal Subedar
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drjpatwa wrote:

Almost all PSU company’s plan have upper limit of cataract even though it is not mentioned in policy wording. They do it under clause of reasonable & customary clause which differs city to city. In my city they pass around 30k for cataract.

@baadshah Hope this helps….

Thanks for the reply
Yes agreed that there will be upper limit either fixed limit and/or as percentage of policy coverage.
.
reasonable & customary clause – something new to learn rolleyes

Deal Subedar Deal Subedar
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Topsey wrote:

My mother had eye surgery as her power was -13 . So had to replace the lens with an artificial one.
They gave 3 lens options. 10,20,50k . There are 2 types of surgeries : I don’t remember the details but we chose the better one and it costed 14k. And chose the 50k lens. And yes only the operation cost was given by the insurance not the lens price. So they are partially correct. But operation cost must not be this high. Or they have increased in 3 yrs maybe

You should have discussed from dimers and could have got thoughts on how to cover all expenses including lens

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