Having medical insurance, senior female however treatment not covered under medical insurance such as dental/cataract treatment or Diagnostic test conducted on Registered Medical Practioner at various diagnostic canters costing more than Rs....

Insurance Expert - Answered on Jun 21, 2022

Question by Jyoti - Jun 21, 2022Hindi

I have mediclaim policy from Oriental Insurance Co since 1992 for 5 lakhs and other from New India Assurance for 7.5 Lakhs under SCUM scheme with my spouse. However both the policies have set a limit of Rs. 40,000 for Cataract surgery even though I have been diagnosed with 1) Cataract Phaco with Panoptix IOL, 2) Pupilloplasty, 3) CTR Implantation for which a renowned hospital billed me as below for separately for each eye. 1) Cataract Procedure Cost. Rs. 27000/- which is approved by Oriental in their contract with Hospital 2) IOL Cost Rs. 49000/- 3) Pulilloplasty Rs. 6950/- after discount 4) CTR Implantation Rs. 1600/ after discount Now in Claim No. 1 Oriental approved. Rs 36,000/- Only and balance Rs 48500 I had to pay Claim No. 2 Oriental approved Rs.73,300/- Only and balance Rs.11250/- I had to pay Surgery was done 1 week apart. In my case I was advised Cataract with multifocal IOL + Pupilloplasty + CTR Implantation So, I need your advice on: How can Insurer Oriental approve and give different claim amount for each eye and how can I claim for reimbursement of balance amount I had to pay. Appreciate your guidance and help.

Ans: Hi Jyoti, hope you are doing well. As you have mentioned that the claim amount for each eye has been different, to understand the reason behind this disparity, you will have to check the documentation submitted to the insurer for both the surgeries. Request you to contact your insurance advisor and discuss the same with the insurer to understand this gap further and help you resolve this issue.

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Roopam Asthana | Answer |Ask -Follow

Answered on Aug 03, 2021

Question by A - Aug 03, 2021Hindi

Is there any insurance company which offers both hospitalisation and non-hospitalisation bills under insurance policy of health including senior citizen? Also, we can claim premium paid u/s. 80d?

Ans: Many insurance companies offer both features either in a single plan or under separate plans. Amongst the two features, the most preferred and essential feature is the one covering hospitalisation expenses.

The non-hospitalisation or out-patient expense cover usually comes at a high premium with a lower limit. However, the hospitalisation plan usually covers non-hospitalisation bills related to pre-hospitalisation & post-hospitalisation period.

There are multiple advanced health insurance plans available offering limit up to 1 crore that cover hospitalisation and pre/post hospitalisation expenses and bundled with other prominent features such as ‘Daily cash allowance’ to count on in case of hospitalisation – to cover expenses that are not usually covered in hospitalisation only linked plans.

Under section 80D of the Income Tax Act, 1961, the premium paid is eligible for tax deduction up to an amount of Rs. 50,000 for senior citizens.

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Sanjib Jha | Answer |Ask -Follow

Insurance Expert - Answered on Jul 29, 2022

Question by Srinivas - Jul 29, 2022Hindi

2. For claim-free years, I am allowed eligibility for Rs. 1500 Medical check-up; this has to be lost as well in case of renewal, as new insurers upon porting do not offer this facility rather, they have some lesser benefit tests (or) nothing at all depending on the plans we chose.

Ans: This is true. Medical check-up is a kind of complementary service which insurers provide along with selective plans. In case of portability, some of the insurers have waiting period & some insurer provide the same from day one.

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Sanjib Jha | Answer |Ask -Follow

Insurance Expert - Answered on Nov 24, 2022

Question by K - Nov 24, 2022Hindi

I have a Mediclaim insurance policy (senior citizens) from National Insurance co Ltd. My wife was operated for Knee replacement surgery. Against the claim of Rs 3.48 lakh, the claim was passed for 51000/- only. I wrote to the Insurance co and wanted to know the reason but no answer. I seek your help and guidance.

Ans: Hi KD, hope your wife has recovered. To answer your query, I advise you to check your policy document again. There are many health insurance policies that have capping/limitations on the list of ailments. You can find the same in the policy documents or policy wording.

I suggest you approach your insurance company and inquire about the same and if you still fail to get a response from them then you can approach insurer ombudsman for this issue.

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