Insurance is refusing to pay entire insured amount post surgery

[User_0887d897]

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User_0887d897
PARTICIPANT
February 21, 2025 at 3:07 pm

Have a mediclaim with UIC (base 2.5 lacs + 5 lacs top-up)

Recently had a surgery, submitted all cashless documents few days prior & underwent the surgery (which was around 4.5 lacs).

While discharge, the claim (TPA) cleared was around 2 lacs, when I pressed for why the remaining was not cleared TPA said its for incremental charges as the were levied since the bed & other medical charges (7k) WHICH were more than 1% of the base policy charges (bed charges above 2.5k were not insured).

While I further pressed, including the top-up the total amount should be 7.5k not 2.5k, the TPA are refusing to elaborate saying they dont have any answers & to consider the base policy and not top-up.

Can someone please clarify what does this mean? Whats the point of top-ups if its not valid in considering the claim itself. Can I push the TPA further to clear the entire amount?

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[Silentsuhani990]

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Silentsuhani990
PARTICIPANT
February 21, 2025 at 3:57 pm

It won’t be 7.5L unless you have a policy which doesn’t have copay / mandatory deduction. Read your policy carefully.

What was the amount cleared for pre-auth?

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[User_0887d897]

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User_0887d897
OP
February 21, 2025 at 4:08 pm

This is a bit complicated. Had to upgrade midway after checking in after the doctor said he doesn’t treat without single/ double occupancy.

Didn’t think of it much back then.

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[Cleverdiksha5363]

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Cleverdiksha5363
PARTICIPANT
February 21, 2025 at 4:28 pm

>the doctor said he doesn’t treat without single/ double occupancy

Not sure about the insurance company, but the doctor definitely scammed you! They can make no such demands!

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[Silentsuhani990]

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Silentsuhani990
PARTICIPANT
February 21, 2025 at 5:15 pm

So when you ‘upgrade’ literally everything becomes pricier other than the medicines and disposables.
And as far as I understand insurance, they will cover only the charges as per the original ‘occupancy’. They will not cover the associated inflation due to the ‘upgrade’.
Best to email your TPA/ insurance provider and get written reply.

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[User_7ad57094]

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User_7ad57094
PARTICIPANT
February 21, 2025 at 4:01 pm

I guess the main issue is the room rent capping which is 1% of base. So 2.5k is max eligibility, and since you got a room for 7k, everything would be paid proportionally.

However you can still make a separate claim against the topup policy for the difference from 2.5L to 4.5L. 2L was covered by insurance, 0.5L self funding, so can claim remaining from topup.

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[User_0887d897]

U

User_0887d897
OP
February 21, 2025 at 4:10 pm

No. Checked the t&c. base policy charges apply sadly.

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[Expertjigar4969]

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Expertjigar4969
PARTICIPANT
February 22, 2025 at 6:02 am

That’s why I do not trust insurance companies. I was finding tips to choose a good insurance coverage with good reviews.

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[Megadude7939]

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Megadude7939
PARTICIPANT
February 22, 2025 at 10:59 am

NAL contact him [https://x.com/NIKHILLJHA](https://x.com/NIKHILLJHA)

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