What is the difference between outpatient treatment and day care treatment? Who is supposed to handle your grievances, the TPA or the insurer? Why is the language of the repudiation letter so important?
We know that health insurance provides cover only if hospitalization occurs only for more than 24 hours. But there are treatments like cataract, chemotherapy, which do not require 24 hour hospitalization owing to use of advance technology. Routine tests and consultations are generally categorized under OPD.
Differences between Day care treatment and OPD treatment
|
Day Care |
Out Patient Department(OPD) |
|
Hospitalization for a few
hours |
No hospitalization |
|
Most policies provide
coverage |
Generally excluded |
|
Limit usually up to sum
insured |
Nil or marginal coverage |
So if your claim is designated under OPD, it might be rejected. But can a TPA deny a claim or handle your grievances against the denial of a claim? No says IRDAI?
In Bipin K. Dave vs. The New India Assurance Co. Ltd.[1] (Award no. IO/AHD/A/GI/0045/2018-19), the insured lodged a claim for CNVM (Choroidal Neovascular Membrane), which was denied by the insurer, citing clauses 4.4.23 and 3.14.1 as the reasons.
As per clause 4.4.23,- treatment for ARMD, RFQMR,ECP,EECP,etc. are excluded.
As per clause 3.14.1- procedures/treatments, usually done in outpatient department, (OPD) are not payable under the policy even if converted as an impatient, in the hospital for more than 24 hours.
The Ombudsman ruled in the insured’s favour as the treatment was taken for CNVM-which was not excluded under the policy.
The insurer’s argument that the treatment was for OPD and hence not covered was rejected by the Ombudsman as this fact was not mentioned in the repudiation letter to the insured.
The Ombudsman observed that it was unfortunate that the insured’s grievances were handled by the TPA and not the insurer. And that this was a clear violation of IRDAI guidelines.
Remember, a claim may have been denied, but you may still have merit in your case. Peruse the language of the repudiation letter carefully. Note all the clauses cited by the insurer for rejection of the claim. Compare with policy clauses or ask your advisor for help. Write to the grievance redressal officer of the insurer if you believe that your case is worth fighting for. And if that does not get you a satisfactory reply, file your case with the Ombudsman or the District Forum.
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