Cygnus_A
29-04-2015, 04:20 PM
My wife had undergone polypectomy by endoscope in a renowned private hospital as a day care patient. We reported to the Gastroenterology department of the hospital in the morning according to prior appointment and she was released in the evening after the procedure which was done after administering an injection which kept her in deep sleep till late afternoon.
She was not admitted in the hospital as that was not necessary since there was no post-procedure complication.
That she will be hospitalized for this purpose was intimated to the TPA well in advance by e-mail which was acknowledged by them.
However, this was not a cashless hospitalization and I had to bear all expenditures.
Later on, I had submitted a claim for reimbursement with all documents in original including money receipts issued by the hospital.
The TPA raised a query about 20 days after claim filing and wanted me to submit 'original copy of the discharge summary'.
I had not received this document from the hospital. Instead, they had issued a digitally signed 'patient advice' which I had already submitted with other documents to the TPA.
On receipt of the query, I approached the hospital authority for the wanted document. They told me that they do not generate any discharge summary for day care patients as they are not admitted. Instead, the 'patient advice' amounts to 'discharge summary' in such cases.
The physician himself who had performed polypectomy and had issued digitally signed 'patient advice' now issued a medical certificate under his manual signature on hospital's official stationary clearly stating the above facts and emphasizing that the 'patient advice' may be considered as 'discharge summary' in this case.
I again submitted this doctor's certificate with a forwarding letter to the TPA about 3 weeks ago from now, but they have not settled the claim, nether they have informed me anything about it.
However, the policy documents of my Insurance Company (New India Assurance) clearly state that in about 20 procedures including Polypectomy, where the patient spends less than 24 hours in hospital, claim will be allowed.
I would be grateful for experts' opinion whether the TPA can decline to clear my claim under the extant rules of IRDA and particularly after Hospital's clarification?
She was not admitted in the hospital as that was not necessary since there was no post-procedure complication.
That she will be hospitalized for this purpose was intimated to the TPA well in advance by e-mail which was acknowledged by them.
However, this was not a cashless hospitalization and I had to bear all expenditures.
Later on, I had submitted a claim for reimbursement with all documents in original including money receipts issued by the hospital.
The TPA raised a query about 20 days after claim filing and wanted me to submit 'original copy of the discharge summary'.
I had not received this document from the hospital. Instead, they had issued a digitally signed 'patient advice' which I had already submitted with other documents to the TPA.
On receipt of the query, I approached the hospital authority for the wanted document. They told me that they do not generate any discharge summary for day care patients as they are not admitted. Instead, the 'patient advice' amounts to 'discharge summary' in such cases.
The physician himself who had performed polypectomy and had issued digitally signed 'patient advice' now issued a medical certificate under his manual signature on hospital's official stationary clearly stating the above facts and emphasizing that the 'patient advice' may be considered as 'discharge summary' in this case.
I again submitted this doctor's certificate with a forwarding letter to the TPA about 3 weeks ago from now, but they have not settled the claim, nether they have informed me anything about it.
However, the policy documents of my Insurance Company (New India Assurance) clearly state that in about 20 procedures including Polypectomy, where the patient spends less than 24 hours in hospital, claim will be allowed.
I would be grateful for experts' opinion whether the TPA can decline to clear my claim under the extant rules of IRDA and particularly after Hospital's clarification?