While visiting her daughter in the United States, Vijay’s mother suddenly started experiencing severe pains in her stomach. On taking her to the hospital, her family found out that she had gall bladder stones. The doctors informed that the treatment would cost her around $30,000 (₹19.3 lakhs). The treatment cost being slightly higher in the U.S., she decided to come down to India and avail the medical facilities here. After reaching Mumbai, Vijay took his mother to a hospital on Thursday. The doctors at the hospital said that an immediate surgery was necessary and fixed a slot for Saturday to have the stones removed. The family was told that the cost of treatment would amount to ₹1,50,000.
Now, Vijay’s father had earlier availed a health insurance plan from a public sector insurance company for the whole family. He was well aware of the fact that in order to avail the cashless hospitalization facility, the insurance company had to be notified 48 hours in advance. The family decided to take the help of OneInsure and got in touch with their claims assistance personnel, Pradeep. He advised them to get the pre-authorization form filled up by the hospital, and submit it to him along with some other necessary documents. All of the documents were forwarded by Pradeep to the TPA and by Friday afternoon they received an approval from the TPA for a sum of ₹1,25,000. Later in the day, Vijay’s mother was admitted in the hospital without any hassles.
Her surgery was successful and she was back in the hospital room by Saturday afternoon. The hospital handed her family a final bill of ₹1,57,000 (they already had an approval by the insurer for ₹1,25,000). The hospital then passed the bill to the TPA, however, the TPA was unable to view the bill. So, Pradeep got in touch with the TPA, who then contacted the hospital to find out what’s wrong. Turns out, the hospital had forwarded the bill to one of the offices in Mumbai, instead of Kolkata, where the policy was issued. (Note - While making a claim with a public sector insurance company, one must forward the documents to the office that has issued the policy). The hospital then sent the bill to the Kolkata office and within an hour, Vijay received a message from the TPA saying that the bill has been approved.
The hospital however, was unable to receive the approval. Pradeep again intervened and found out that the TPA had an incorrect email ID of the hospital. This error was rectified and the approval was finally sent to the correct email address. For a claim of ₹1,57,000, all that Vijay had to pay was ₹1,200 in non-medical expenses and ₹150, which was the cost of registration. The rest of the expenses were taken care of by the TPA. Vijay’s mother was discharged later that day and taken home. If it wasn’t for the assistance provided by Pradeep, Vijay would have had to pay the hospital bills upfront and later file a claim with the insurance company. This would have required the family to put in considerable time and efforts, and the whole process wouldn’t have gone this smoothly.
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