copy pasting a post here
A senior citizen known has a senior citizen national insurance health insurance, one of the worst insurer's out there. He had to undergo a planned procedure. The hospital was not under cashless tieup with the insurer. The bill amount was 28000/- The insurer after 2 months has approved only 14000/- and has deducted most of the money from Operative fee head. The deductions were made from the pharmacy etc. section also but most of the deductions were from the operative fee head. Their customer care and local office are useless. Reached to the TPA somehow and they said that hospitals empanelled with them under cashless do this procedure including all charges for 14000/- only. Asked the guy to transfer the call to his senior, he said that they are liable to pay 14000/- only. He said that the rates about the same procedure can be confirmed from the hospitals which have a cashless tieup with them. Just want to understand is this correct? Can we ask them for this info in writing?
@drjpatwa @atx88 @guest_999 @Ramta_Jogi @Sudarshan61 @raghupro
Please get it in writing.
Unless the policy have sub limits or you are not hitting the room rent limit its totally wrong
cant compare cost of treatment for two different hospital.. it has to be reimbursed on actual..
written complain to IRDAI, CC branch office and what ever email you have.
Sudarshan61 wrote:Please get it in writing.
Unless the policy have sub limits or you are not hitting the room rent limit its totally wrong
cant compare cost of treatment for two different hospital.. it has to be reimbursed on actual..
written complain to IRDAI, CC branch office and what ever email you have.
What type of sublimits are you talking about here paji? Every policy from this company has a room rent limit but it was not hit as patient was called in the morning and discharged in the evening. This is the clause about which they are talking about
"Reasonable & Customary Clause" 
If u ask them in writing for deduction, i presume they will write these 3 words.
U can fight. But it depends whether they will pass it or not.
If the bill generated for 28k is quite valid and has all of it covered under the right headers, this is completely wrong.
Sad part is the person being a senior citizen, he wont even't have the energy to run behind these folks to get justice.
drjpatwa wrote:But sir is their justification given allowed by irdai? Are other insurers, as per ur experience, doing this? I mean cashless hospital empanelled with them do a procedure for 14k, non cashless one did for 28k and they deducted everything because as per them they are liable to pay max this much only. Btw we enquired about same procedure from some other hospitals, everyone quoted 26k-40k, even hospitals empanelled with them. Don't know why they are stuck on this amount. Copy of the clause https://imgur.io/a/b...QA + @raghupro @Sudarshan61"Reasonable & Customary Clause"
If u ask them in writing for deduction, i presume they will write these 3 words.
U can fight. But it depends whether they will pass it or not.
kukdookoo wrote:In every insurance company this clause is there. Why it is there, let me give example.
But sir is their justification given allowed by irdai? Are other insurers, as per ur experience, doing this? I mean cashless hospital empanelled with them do a procedure for 14k, non cashless one did for 28k and they deducted everything because as per them they are liable to pay max this much only. Btw we enquired about same procedure from some other hospitals, everyone quoted 26k-40k, even hospitals empanelled with them. Don't know why they are stuck on this amount. Copy of the clause https://imgur.io/a/b...QA + @raghupro @Sudarshan61
drjpatwa wrote:Thanks Sir one last question, the procedure was from a 40 bed hospital for 28k. The insurer said that the super speciality 100 bed hospital chagres 14k for the same procedure. We asked them the price for the same package, they said its 32k. Is there anything one can do here? Can we ask the insurance company in writing that the xyz hospital that they are mentioning will charge 14k for this procedure? I am sure they won't give this in writing though.
In every insurance company this clause is there. Why it is there, let me give example.
Suppose, u have 10 Lac policy without any capping. If u want to go for cataract surgery & if doctor & u ties up, doctor can make charges of Operation cost for even 8 lacs (Which later on u & doctor can share profit from it). Now as policy is without capping, ideally company is liable to pay full amount. To stop such fraud, every insurance company has this clause.
Now it is up to company when they want to apply this clause. How much access amount should be there to apply this clause is not written anywhere. That's why I always say that in Health insurance to be with good insurance company is must else they can literally **** u.
In ur case, u should fight. Amount is not much that they put such clause. Most probably U will win the case in consumer forum but it will waste ur lots of resources, time etc.
kukdookoo wrote:Call me. I will explain in detail.
Thanks Sir one last question, the procedure was from a 40 bed hospital for 28k. The insurer said that the super speciality 100 bed hospital chagres 14k for the same procedure. We asked them the price for the same package, they said its 32k. Is there anything one can do here? Can we ask the insurance company in writing that the xyz hospital that they are mentioning will charge 14k for this procedure? I am sure they won't give this in writing though.
kukdookoo wrote:Now-a-days everything has a pre-decided package. By everything, I mean post planned procedures or surgeries, not accidents. We are generally not informed of all these package rates beforehand, hence no matter if we buy insurance without capping, still this capping will apply.What type of sublimits are you talking about here paji? Every policy from this company has a room rent limit but it was not hit as patient was called in the morning and discharged in the evening. This is the clause about which they are talking about
atx88 wrote:Thanks paji. No empanelled hospital will give any quote in writing.
Now-a-days everything has a pre-decided package. By everything, I mean post planned procedures or surgeries, not accidents. We are generally not informed of all these package rates beforehand, hence no matter if we buy insurance without capping, still this capping will apply.
For example: In one of my friend's case, tympanoplasty (ear drum reconstruction surgery) had package rate of 92k from his insurer (corporate tpa medibuddy). So all charges upto 92k will be payable. Now if he took lesser category room like a shared room, the bill would also be lower like ~80k, entire amount is paid even if it includes some non-payable items. But if he took a suite, surgery charge from hospital would shoot up to 1.2-1.3 lakh, and out of it, only 92k will be paid by insurer and rest he has to bear.
So that explanation that other empaneled hospitals are doing it for 14k is a wrong explanation, because a bill from hospital depends on several factors like hospital's premiumness, room type, etc. Also, it may be possible that the 28k bill may have few more things and not just a single procedure, whereas 14k quote from other hospitals might be just for that procedure without adding those other things. TPA are generally not people with good IQ. So you have to fight for it. Also, if you can get a quote of 32k from their empaneled hospital for same procedure, then send that to them over email and ask why are they lying and why case should not be filed against them for wilful fraud and cheating against senior citizen patient. Put their senior people in cc, not just TPA, but also of the insurance company. Hopefully this helps.
Majority people here don't know how this industry works. Even Apollo hospital can have rate of 14k for the same procedure !!!
drjpatwa wrote:"Reasonable & Customary Clause"
So what you are saying here is this phrase in any sentence of the policy is a red flag; is that so?
Ramta_Jogi wrote:Every insurance company will have that sentence else they will go bankrupt. More important is their intension, when they want to apply this clause.So what you are saying here is this phrase in any sentence of the policy is a red flag; is that so?
