What to do if full amount is not given under Health Insurance claim
27-Sep-2023 (In Insurance Law)
I was admitted in Apollo hospitals Greams road for Chronic Calcific Pancreatitis (13th - 14th Sep 2018) : ERCP + Stent Removal + Sphincteroplasty + Stone Extraction + PD Stending was done. The total bill amount was Rs. 73,409. But the pre-auth was done only for Rs. 53,000 with a co-pay of Rs.5,300 hence only Rs. 47,700 will be borne by the insurance. I had to pay nearly Rs.26,000 When checked with the Vidal TPA i was told that Rs. 53,000 is what is allowed for the package. The package was meant for 'PANCREATIC STENT IN SITU,FOR ENDOSCOPIC RESTENTING'When checked with the Hospital the cost was high because more complex procedures were involved: ERCP + Stent Removal + Sphincteroplasty + Stone Extraction + PD Stenting. I have confirmed this with the hospital the reason for exceeding the package amount and got a letter from one of the doctors attached it as a proof while submitting the claims through the hospitals. Vidal TPA is still denying claims nor replying to any emails
The TPA is not the insurer and the contract is between you and the insurer and the terms are mentioned in the policy and the TPA is only a facilitator and hence they can not dictate the terms . If you are not happy first lodge a formal complaint and then proceed legally.
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