Ms. Archana, a client of OneInsure, was admitted in one of Mumbai’s reputed hospitals after suffering from a persistent high fever for a couple of days. She had been taking antibiotics prior to being hospitalized on the advice of her family doctor. After she was admitted, the doctors conducted a series of medical tests and found that she was suffering from a severe case of urinary tract infection. Right away, she was put on antibiotics of a stronger dose, which was given to her intravenously. Her health began to recover and she was discharged on the third day. She decided to pay the medical bills herself and later file a reimbursement claim with the insurance company.
When OneInsure received the reimbursement file, its claims team realized that some papers were missing, including the discharge summary from the hospital. OneInsure, with the authorization from Ms. Archana, collected all the missing documents from the hospital and got them in place to submit to the insurance company. However, on close examination of the discharge summary, OneInsure noticed that there was a comment from the hospital about Ms. Archana (related to her condition at the time of admission). The term ‘AFEBRILE’ was mentioned in her file which meant that she did not have fever at the time of hospitalization. This would have a serious impact on her claim as the primary reason cited by Ms. Archana was fever.
OneInsure got in touch with Ms. Archana, and she told the insurance broker that she had a fever of 104 degrees F when she was admitted. This was then communicated to the hospital and they admitted their mistake and got the same corrected in the final discharge summary. The claim was then processed and Ms. Archana received a final sum of ₹ 53,000, after some deductions of non medical expenses. Had the claims team at OneInsure not noticed the improper narration from the hospital, the claim process would have turned into an investigation between the insurance company and the hospital and the payment would have been extremely delayed.
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