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Medical insurance must cover pre-op bills too
Economic Times, January 07, 2019

The commission also specified that expenses incurred on consultation and pre-surgery tests cannot be refused just because the policy holder had undergone them 30 days before the surgery.

Mumbai: If you pay from your pocket for tests, including an MRI, before a surgery, you are entitled to a refund from your mediclaim insurance company. This order favouring policy holders was passed by the state consumer commission recently. The commission also specified that expenses incurred on consultation and pre-surgery tests cannot be refused just because the policy holder had undergone them 30 days before the surgery.

The commission brought to book New India Assurance Company Ltd for rejecting a reimbursement claim made by a Dombivli resident, V Sridhar. It pertained to presurgery and non-medical expense (gloves for medical use) incurred on his son’s knee surgery.

Sridhar’s son was hospitalised on April 18, 2012. While Sridhar claimed Rs 58,000, the insurance company approved around Rs 49,000. The commission’s order states that the company will now have to pay the full claim of Rs 58,000 along with Rs 35,000 as compensation.

In his complaint, Sridhar said the mediclaim policy covered his son, wife and himself for Rs 1 lakh, and that when he first submitted his claim, the company agreed to honour it only to the extent of Rs 17,852. When he made inquiries, the company agreed to reimburse Rs 30,856, but refused to compensate for hospitalization and non-medical expenses.

‘30-day norm not always applicable’

The company’s advocate contended that ‘pre-hospitalisation’, as mentioned in the policy prospectus, means relevant medical expenses incurred during a period of up to 30 days prior to hospitalization.

However, the commission pointed out that an MRI was done on March 13, 2012, during consultation with the doctor about the surgery. “The MRI test was necessary before surgery,” the commission noted. “Under these circumstances, the insurer could not have refused to pay incidental and consequential expenses merely on the grounds that it was not done within 30 days.”

The consumer body also said that when the policy’s assured sum was Rs 1 lakh and the claim made for a much lesser amount, and was supported by documents, the company ought to have allowed it as it included fees of surgery and consultation charges, MRI charges, gloves among other medical paraphernalia.

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