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Sanjib

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Insurance Expert - Answered on Jul 28, 2022

Sanjib Jha is the CEO of Coverfox Insurance. His expertise includes health and auto insurance. He has over 22 years of experience in the financial sector. He has completed his post-graduation from the Institute of Company Secretaries of India.... more
Anoop Question by Anoop on Jul 28, 2022Translate
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My Oriental Mediclaim coverage is for Rs 5 lakh under Royal Mediclaim cashless scheme vide PNB. I have completed 36 months, a conditional requirement (a facility only for PNB customer).

In this regard I have a few questions...

Ans: Hi Anoop, thanks for sharing your queries, will take them one by one.

1. What's the meaning of 5 lakh coverage? Will I get a full 4.95 lakh for both knees transplant (my hospital package is costing 4.95 lakh from entry to exit)?

Sanjib Jha:  A coverage of 5 Lakh means your policy covers you up to 5 lakh and you can claim it. However, the coverage amount for knee transplant depends on insurer to insurer as few of the policies having certain capping on the coverage amount for such treatments.

2. When the hospital sent the proposal to TPA, only 2.47 lakh were provisional sanction. What's the meaning of provisional? I was told that the final amount will be settled once final bill is produced by the hospital. Does it mean that 4.9-2.47=2.43 lakh or so, will be settled and remitted to the hospital by Oriental insurance? 

Provisional Sanction amount is the amount that the insurer approves based on the ailment i.e., knee transplant in your case. The rest of the amount approval is provided based on the final bill generated by the hospital.

3. When I sought clarification from TPA, I was verbally told that now the final amount cannot be decided. Only after the final bill it can be. Nothing said on email. No replies from Oriental insurance of my email query.

For policies issued by Oriental, the claims are handled by TPA (Third Party Administrator). I advise you to raise the concerns to TPA via email or via TPA desk to get the clarification. Also, the insurer can provide the final approval after the final bill is generated by the insurer, deducting the non-approved cost as per policy terms & condition.

4. Hospital insists that I deposit 50% (2.5 lakh) cash from pocket before admission.

As it seems that the insurer has provided pre-approval for 2.47 lakh, the rest amount you will have pay to the hospital & the same will get approved by the insurer once the final bill is generated by the hospital.

5. If I have to pay cash, then where is the cashless scheme?

I advise you to check the terms of your policy. Often certain treatments are not covered in particular policies, which is why it is extremely important to read your policy document thoroughly and ask all your queries to the agent/Insurer before purchase. For specific ailments, there are add-ons offered by insurers and accordingly one should opt for those add-ons.

DISCLAIMER: The content of this post by the expert is the personal view of the rediffGURU. Users are advised to pursue the information provided by the rediffGURU only as a source of information to be as a point of reference and to rely on their own judgement when making a decision.
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I read your today's article about Mediclaim: What You Must Know. Thank you for some important information and points shared. I have some questions about the Mediclaim policy. I have been buying a Mediclaim policy since 2007 and I have not claimed it till last month. Last week I was hospitalized for gall bladder stone surgery. When I asked the hospital to use the cashless option on my Mediclaim policy for claims they gave an estimated cost of about 1 lakh. And same if I claim myself, they gave an estimated cost near about 55 thousand.  1. Why and what is the difference between these charges? How did the TPA approve cashless? Is there any guideline or standard process for hospitals that can claim more charges in cashless options? 2. Why do cashless charge more? Due to this type of charges for cashless claims the sum insured amount decreases after treatment. We can utilise the same difference charges amount for another treatment.
Ans: Hi Vilas, in order to understand the difference in the estimated costs, you should ask the hospital on what parameters they have estimated the two costs. Questions on treatment protocol, room charges and type, doctor’s fee etc., should be asked.

When choosing cashless treatment, the patients often opt for the best facilities that they may not have opted for otherwise. Sometimes hospitals may run some additional tests as well in order to avoid back and forth on your claim settlements, when it is a direct transaction between insurer and the hospital.

However, if you feel that you are being overcharged, then you should report any discrepancy in what you are being charged for, to the insurer. Insurance companies take such cases very seriously, which is why insurers have preferred network hospitals that agree on a certain pricing for various treatments and other tariffs.

In case it is observed that there is any abuse of cost or sum insured then there is a chance of being de-paneled and hence a check is in place.

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This is Bobby here and have a few questions related to your article (enclosed), Mediclaim: What You Must Know Would like to know, with your experience in this field, as to: 1. Which mediclaim policy or policies, currently in INDIA and especially Mumbai has all the required coverage as mentioned in your article 2. We are a family of 3 with a school going child and both of us are aged 45 3. Have acquired diabetes a few months ago and have hepatitis B and kidney stones  4. What should be the approximate premium, per annum to cover all that is mentioned in your article and keep us safe from the issues arising out if and when we really require hospitalisation and save us from rejected claims.   5. Presently we are covered under Mediclaim policy from Star Health Would be highly obliged should you guide us on the above to make our lives easier.
Ans: Hi Bhupesh, there is no ‘one size fits all’ concept with health insurance. Health insurance is based on preferences of the customer and then the premium quotes are generated based on those factors. You can use insurance broking websites to compare the offerings on the mentioned 5 factors and the premiums for various policies that will help you to compare their benefits and make an informed choice. Depending on your priorities, weigh out the factors and decide accordingly.

Since you have mentioned about your family, you can opt for Family Health Insurance policies with an appropriate sum insured to cover your entire family. Like I have mentioned before, premiums are unique to individuals depending on their preferences, the sum insured they deem suitable, the riders they choose, their medical history etc.

What you can do to ensure you buy the correct policy for yourself is to evaluate policies carefully, keeping in mind the 5 important parameters.

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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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