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 Mr. Tripathi, greetings to you. To answer your first question as to why Aditya Birla won’t provide you with cashless claim as opposed to TATA AIG is because the policy you bought from Aditya Birla is a ‘Super top up plan’ which basically means it is an addition to your base policy which in your case is your TATA AIG policy.

Super top up policies do not offer cashless claims but only provide reimbursements.

The one lakh gap, unfortunately, cannot be filled at this point. However, while renewing your policy you can opt for increased sum insured with TATA AIG. The insurer will ask you a set of questions and schedule medicals to analyse your risk profile. Post that based on your reports, the insurer will take a decision on increasing the limit.   

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.

Ans: Health check ups are not covered in medical insurance however check your policy if it offers free health check up

Ans: Here's how you can potentially minimize your out-of-pocket expense for cataract surgery with ECHS and your insurance:
1. Understand Your ECHS Coverage:

ECHS has pre-defined package rates for cataract surgery. These rates may cover a specific type of lens (likely monofocal).
Check the ECHS policy documents or contact your local ECHS office for details on their coverage for cataract surgery, including the type of IOL (Intraocular Lens) covered.
2. Explore Options with the Hospital:

Discuss your situation with the empaneled hospital performing the surgery.
Explain your ECHS coverage and the additional insurance benefit for a better lens.
Hospitals might be able to provide a breakdown of costs for surgery with a monofocal lens (covered by ECHS) and the additional cost for the better lens you desire.
3. Leverage Your Insurance:

If the chosen lens falls under the Rs. 30,000 limit of your insurance plan and isn't covered by ECHS, you can likely claim the additional cost through your insurance.
Contact your insurance provider and understand their claim process for cataract surgery with a specific lens type.
Here's a possible scenario:

Let's say the ECHS covers surgery with a monofocal lens costing Rs. 20,000.
The better lens you desire costs Rs. 10,000 extra (total cost Rs. 30,000).
Since it falls under your insurance coverage limit, you can potentially:
Pay Rs. 20,000 to the hospital, covered by ECHS.
Claim Rs. 10,000 for the lens upgrade from your insurance company.
Important Note:

This is a simplified scenario. Actual costs and claim processes may vary.
Recommendations:

Get a written cost breakdown from the hospital for surgery with different lens options.
Contact your insurance company and understand their claim process for cataract surgery with a specific lens type.
Once you have this information, you can calculate the potential out-of-pocket expense for each scenario (monofocal vs. preferred lens).
By following these steps, you can make an informed decision about the lens and minimize your out-of-pocket expense for cataract surgery.
Best Regards,

K. Ramalingam, MBA, CFP,

Chief Financial Planner,

www.holisticinvestment.in