Pre Approved Hospitalisation Claim Rejection

This topic has 7 replies, 4 voices, and was last updated 1 year, 3 months ago by Quickguru4523.

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- March 7, 2025 at 10:43 am #40096 Reply
  User_e04c8b23
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  User_e04c8b23
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  March 7, 2025 at 10:43 am
  
  Hello,
  I recently faced an issue where my pre-approved cashless hospitalization claim was unexpectedly rejected by the insurer. The insurer had initially approved the cashless treatment, but after the hospitalization, they refused to settle the bill saying it’s daycare which was already mentioned in the prescription before.
  
  I have already escalated the matter to the TPA via email with all supporting documents. However, I want to understand my legal options if they don’t reverse the decision.
  
  Has anyone here successfully contested such a rejection? What steps worked for you?
  
  Does consumer forum work for this?
- March 7, 2025 at 11:02 am #40099 Reply
  Cleversajal8453
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  Cleversajal8453
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  March 7, 2025 at 11:02 am
  
  Consumer forum does work, but I would advise you to make a complaint before IRDAI (assuming your claim is still in the process, I don’t know what TPA stands for) Grievance Redressal Portal, may save you a trip to the Consumer Forum as well.
- March 7, 2025 at 11:11 am #40098 Reply
  Expertstar2218
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  Expertstar2218
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  March 7, 2025 at 11:11 am
  
  NAL, but share the complete details at least. Like what the treatment and procedure was. Who is the insurer and the TPA?
- March 7, 2025 at 11:54 am #40097 Reply
  Quickguru4523
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  Quickguru4523
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  March 7, 2025 at 11:54 am
  
  In house Hospital care is at least 24 hours stay without a break day care centre is not considered eligible per insurance policy
  - March 7, 2025 at 12:05 pm #40100 Reply
    User_e04c8b23
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    User_e04c8b23
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    March 7, 2025 at 12:05 pm
    
    Understandable but that was already mentioned in the pre approval documents shared.
    - March 7, 2025 at 12:07 pm #40101 Reply
      Quickguru4523
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      Quickguru4523
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      March 7, 2025 at 12:07 pm
      
      That you now have to challenge to get paid from insurer as they would claim it was a clerical mistake
      - March 7, 2025 at 12:08 pm #40102 Reply
        
        User_e04c8b23
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        U
        
        User_e04c8b23
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        March 7, 2025 at 12:08 pm
        
        That’s why I asked if there is something I can do legally to put pressure?
        
        March 7, 2025 at 12:58 pm #40103 Reply
        
        Quickguru4523
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        Quickguru4523
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        March 7, 2025 at 12:58 pm
        
        File a consumer court complaint
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