Medical Insurance Claim – Consultation Charges not paid to me !

POSTED BY Farshid Bokdawalla ON August 19, 2014 5:38 pm COMMENTS (2)

I have health insurance provided by my employer through a TPA service provider. Recently I had to undergo surgery for torn ankle ligaments. I have submitted all requisite documents and my claim has been approved. About 10% of my claim amount which includes Consultaion Charges, Medical Imaging & Misc. charges have been termed “Non-Payable”, the reasons for which I have not been disclosed.

I wish to seek advise from fellow members on this forum as to whether it is possible for me to seek clarification from the TPA on the same by law. Also if they choose to not reimburse me for my Imaging films (MRI) can I ask them to return the films back to me?

Thanking you

2 replies on this article “Medical Insurance Claim – Consultation Charges not paid to me !”

  1. Lokesh Jain says:

    Hi Farshid,

    Ideally, the answer to your question will be in your policy terms itself, though I am enumeraing some of the reasons why you may be denied the claim for these charges. Though you can definitely ask the reason for non-payable claim. You can ask for the MRI scans back definitely.

    Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period.

    Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees etc,.

    Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital.

    Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalisation period.

    Treatment which is continued before hospitalization and continued even after discharge for an ailment / disease / injury different from the one for which hospitalization was necessary.

    1. Farshid Bokdawalla says:

      Thank you Mr. Jain. I received about 91% of my claim amount & I have got my MRI Scans back too. Thank you once again

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