TPA denying claim saying advanced procedure
- 735
- 8
-
- Last Comment
My father is scheduled for TAVI (Transcatheter Aortic Valve Implantation) procedure next week. He is 70 years old and already had bypass surgery in 2010 so conventional open heart surgery is not an option. Hospital came with estimate of 16L. I have corporate insurance policy from New India insurance and TPA is Mediassist.
Mediassist asked for the following information from the hospital (Sentence is half broken only)-
"1. Please share the cost of estimate for the conventional treatment/ surgical procedure TAVI instead of redo sternotomy and open replaceme
2. Please provide the treating doctor certificate to justify the need of hospitalization since based on available medical information hospitalization does not seems to be indicated indication for TAVI instead of redo sternotomy an"
Hospital shared the doctor certificate that TAVI is only option. Hospital did not share the conventional surgery estimate since they had already shared TAVI estimate. Next mediassist came with approval letter saying advanced procedure not allowed and sanctioned only 3L. My policy limit is 10L plus there is some corporate buffer.
I have been asking Mediassist to show where it says in the policy condition that TAVI is not covered. Even for cancer advanced procedure there is 50% copay mentioned in the policy. But Mediassist has not been answering this question. They just say that advanced procedure is not covered and not everything will be listed in the policy.
What should be the course of action now? Keep calling mediassist contact person? escalate to ombudsman after the surgery ? i tried complaining against the TPA in United india insurance grievance but that requires a claim id which is not yet generated. What should be the role of the employer in all this?
- Sort By
Please ask an agent from the TPA to work with you... I hope that shall do the wonders...
And may who is hospitalized be back to normal... I WISH...
* Actually man, I know how it feels to get 'fked up.... I lKNOW,,, nobody helps...
** SLEEP FOR TODAY,
KAL DD ke friends help karenge.... OK ? @dcb_lover
If nothin works , try 10k bribe...
Baby steps:
1. Email mediassist TPA grievance cell with cc to your corporate HR explaining the issue. Directly ask them to cite the point in the policy where it mentions your desired/needed treatment is not covered. If they can't, it's arbitrary denial.
2. If the above doesn't work, yes, Ombudsman is the way to go. It'll take time in this route though, like several months and several dates for you to appear afaik.
At the end of the day, not much to worry as long as the policy doesn't explicitly mention any restriction pertaining to your dad's treatment. Main thing is you must have patience while dealing with these animals
Raise your grievance at bimabharosa, by doing so you will have companies official stand, after that you can proceed for insurance ombudsman.
Update, they sent this mail. -
Claims will be processed under reasonable & customary clause (coverage under conventional method), advanced procedures are covered only if insurance provider calls out in the policy documents (same as cancer treatments).
We have referred your case with the insurance provider with the documents shared by the hospital for their medical opinion on admissibility of the procedure. May I know the tentative discharge date.
I had a similar experience, where they denied my claims saying overlimit. This is what I would suggest you to do:
1. Every organisation have a dedicated member from TPA, who co-ordinates all the approvals. Involve them, if not easy escalate to your HR to find that guy, get on a call with him/her they are ultimately somewhat responsible to get this approvals/limits things sorted.
2. Keep asking for mentioned exclusion in policy, again all in email if possible. I know there's no way you can check the policy on portal. But the poc do have the policy, they shared with me when I escalated this to HR leads.
3. There's some CMO guy to whom these queries got re-directed to( idk a lot about it ), ultimately he decides things case-to-case basis. Try to hunt for them.
4. Make sure you take no responsibility on yourself, if TPA/insurance company ask for any document, put it on them to co-ordinate with hospital directly. Let's say they ask you to get the daily drug chart or planned treatment, ask them to talk to hospital directly, if you enter once & take it on yourself to sort out, it's a mess trust me!
5. Try opt for reimbursement instead of cashless ( this will help you buy more time to settle the argument with insurance company ). I myself did cashless but I think when it's cashless once the final billing is done from insurance company to hospital, it gets tough to get it rectified/fight against it. But this is just a thought. ( please do proper research on this )
6. Ombudsman is last resort, but takes long-long.
I wish things to go smooth & good health for your father. If you need any other help, feel free to dm.
Check t&c of policy. Employer health insurance is often not comprehensive and do contain sublimits for advanced or modern treatments.
Try contacting HR from your company regarding this ?
They may have some information or else they will guide you what to do next ?