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Ramalingam Kalirajan |7163 Answers |Ask -Follow

Mutual Funds, Financial Planning Expert - Answered on Jul 11, 2024

Ramalingam Kalirajan has over 23 years of experience in mutual funds and financial planning.
He has an MBA in finance from the University of Madras and is a certified financial planner.
He is the director and chief financial planner at Holistic Investment, a Chennai-based firm that offers financial planning and wealth management advice.... more

Question by Danny on Jun 24, 2024Hindi

Pre and Post hospitalization. As per my understanding all consutations, tests and medicines connected with /advised by may be various doctors for the procedure for being admitted needs to be paid by the insurer if documents and advices are available. The insurer states that only tests recommended for the particular procedure will be paid. for example , for kidney stone procrdue, the doctor advices to take a series of tests before admission which may be directly related to or may be not directly related or may be a test result which needs to be known mandatory ( ex an HIV test before admission) The insurer dosent pay for the mandatory HIV test or a general blood test like an LFT or CBC . Kindly confirm

Ans: Your understanding of pre- and post-hospitalization coverage is mostly correct, but there can be nuances based on the insurer's policy and specific terms and conditions. Here’s a breakdown:

General Coverage for Pre and Post-Hospitalization:
Pre-Hospitalization: Typically, medical expenses incurred up to a certain number of days (e.g., 30 days, 60 days) before the hospitalization are covered. These include consultations, diagnostic tests, and medications directly related to the condition for which the patient is hospitalized.
Post-Hospitalization: Medical expenses incurred up to a certain number of days (e.g., 60 days, 90 days) after discharge are covered. These generally include follow-up consultations, diagnostic tests, and medications needed for recovery.
Specific Coverage Details:
Directly Related Tests: Diagnostic tests and consultations that are directly related to the treatment or procedure for which hospitalization is required are typically covered. For example, tests specifically to diagnose or assess the kidney stone would be covered.
Mandatory Tests: Some mandatory tests, like an HIV test before surgery, may be required by the hospital or medical guidelines but might not be covered if they are not deemed directly related to the specific condition being treated. Insurers often scrutinize these and may exclude them from coverage.
General Health Tests: General tests such as Liver Function Test (LFT) or Complete Blood Count (CBC) that are part of routine pre-surgery assessments might not be covered if they are not directly linked to the treatment of the condition for which hospitalization is required.
Steps to Clarify Coverage:
Review Policy Document: Carefully read your health insurance policy It will outline what is covered and any exclusions.
Consult Insurer: Speak directly with your insurance provider or a representative to get clarity on what specific tests and consultations are covered under pre- and post-hospitalization.
Get Written Confirmation: If there is any ambiguity, request written confirmation from the insurer regarding the coverage of specific tests or procedures to avoid surprises later.
Example Scenario:
For a kidney stone procedure, if your doctor advises an HIV test as part of the pre-surgery requirements:

Insurer's Perspective: The insurer may argue that the HIV test is a general mandatory requirement for surgery and not specifically related to the treatment of the kidney stone.
Your Argument: You could argue that the HIV test is part of the necessary pre-surgical protocol required for the safe conduct of the kidney stone procedure, thus should be covered.
In conclusion, while pre- and post-hospitalization coverage aims to cover necessary medical expenses related to a condition, the specifics can vary. It's crucial to have clear communication with your insurer and understand the terms of your policy to ensure appropriate coverage.

Best Regards,

K. Ramalingam, MBA, CFP,

Chief Financial Planner,

www.holisticinvestment.in

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