Mediclaim Claim Escalation - Need Guidance

159°
Deal Subedar
amdoinggood123
Hello dimers, need guidance on claim deduction by the health insurance company / TPA.

Claim Amount: 218000
expected passing amount = 200000
claim amount passed = 79000
deducted amount = 141000 (200000-79000)

Dr. fees 90k, deducted 60k
Anaestetic fees 26k , deducted 17k,
OT charges 40k, deducted 28K

these are the major deductions
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12 Dimers
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Generous Generous
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claim rejection / downgrade cases are increasing day by day .

my heart cries out for those whose hard earned money is digested by these money mongers . 

Benevolent Benevolent
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bkl these days check one's phones location data to verify claims. bstards send a recovery agent type of guy for this, mostly private ones are doing this.
Helpful Helpful
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Room rent must be outside the range allotted.

Tech Guru Tech Guru
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Most probable reason

Details are missing in OPs post

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Deal Cadet Deal Cadet
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Was it a delivery case?

Deal Subedar Deal Subedar
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No, it was for Prostate Operation of my Father

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Deal Newbie Deal Newbie
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Which insurance?

Deal Subedar Deal Subedar
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New India

Trailblazer Trailblazer
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There r some pros for health insurance claims check twitter they can do it for with charge

Deal Subedar Deal Subedar
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can you dm me those details. Thanks in advance

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Deal Subedar Deal Subedar
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Read t&c's of policy

Generous Generous
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this post is irrelevant.. unless u provide with the details of what are deductions made. 

Deal Subedar Deal Subedar
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okay, will share by today evening or tomorrow morning

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Benevolent Benevolent
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Mata Rani unhe jaldi theek kare

share name of the policy along with policy wording. and for how long its going on and any claims made before?

Deal Subedar Deal Subedar
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he has recovered fully, thanks

Deal Subedar Deal Subedar
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remarks of deduction: reasonable & customary

Benevolent Benevolent
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then you wont get anything more. still check my other comment and share what i have asked for.
Generous Generous
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Please mention these 2 things, without which nothing will help:

1. Room rent (per day) of the room selected.

2. Room rent allowed as per your policy.

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Now, assuming the chosen room was within policy's room rent range, and charges deducted solely due to reasonable & customary clause, feel free to file a case in consumer court, with charges like:
- no transparency by insurer as on what basis they've unilaterally decided those 'reasonable' charges, yes you accepted their reasonable clause because they forced that consent in a one-way manner, either you accept their condition or remain uninsured, but bigger issue is that they never shared those details and deliberately kept those details hidden until a claim is raised
- no information provided beforehand like what is their reasonable amount list by disease/procedure while buying insurance
- reasonable cannot mean deduction by 63%, and if they're deducting so much it means they're indirectly denying insured people of availing good quality healthcare in private hospitals even though they're taking full premium for full coverage
- Also mention things like room charges, doctor fees, OT fees, etc are all outside your control.

Iske baad 3 possibilities honge:
1. Nobody from the insurance will show up in court on 2-3 hearing dates, in which case you'll automatically be provided financial relief you ask for. And the insurance will probably not renew your insurance next year.
2. You'll win, get appropriate claim amount along with mental harassment damages & legal coverage. And the insurance will probably not renew your insurance next year.
3. You'll lose, but atleast you fought. If you feel this happening halfway, you can try to settle on a lesser amount. And the insurance will probably not renew your insurance next year.

PS: Bhavukta me beh ke don't take advice here & above points very seriously just because they feel nice and logical to hear, consult an actual lawyer. Courts do not work on logical deductions.

Good luck!

Benevolent Benevolent
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And the insurance will probably not renew your insurance next year
on what basis paji? i dont think he will get an insurance for his father from some other company due to age + claim taken, maybe he will but the premium will be very high.

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