reasonable and customary charges in health insurance
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
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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.
Majority people here don't know how this industry works. Even Apollo hospital can have rate of 14k for the same procedure !!!
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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.