Ramesh Ji was having a retina problem one of his Doctors advised treatment through Intravitreal injections – a modern treatment Ramesh had health insurance and checked with them about the acceptability of treatment but he was refused.
Sunder was also not clear whether Oral chemotherapy will be allowed as treatment under his group insurance with his employer because TPA was advising in favour of traditional chemotherapy.
Medical science is advancing and new treatment methods are developing However standard protocols of TPAs and Insurance Desks do not find these treatment methods in their guidelines hence they refuse to accept such new methods Patients remain under dilemma whether to undertake these new methods or go for traditional methods approved by Insurance Companies Most of the time new methods are more expensive and a burden on insurance companies.
However, on 22 July 2020 IRDA came up with a circular Ref No IRDA/HLT/REG?CIR/193/07/2020 instructing all Health Insurance Companies to accept Modern Treatment methods with immediate effect details of circular are given below:
- Applicable on all Health Insurance Plans i.e Individual as well as Group Contract
- Applicable to all standard products including Arogya Sanjeevani
- Section 1 gives guidelines on Standardization in Health Insurance so that interpretations remain same for all Insurers
- Clarity in definitions of Pre Existing Diseases and Exclusions
- Clarity on acceptance of Modern Methods of treatment
Modern Treatment under Inpatient Care/Daycare or Domiciliary Hospitalization
Following modern treatment has been allowed in Chapter V of circular as inpatient/ Daycare or Domiciliary hospitalization as mentioned below:-
- Uterine Artery Embolization and HIFU
- Balloon Sinuplasty
- Deep Brain simulation
- Oral Chemotherapy
- Immunotherapy – Monoclonal Antibody to be given as an injection
- Intra vitreal injections
With effect from October 2020, all health insurers have been instructed to include the above treatments in new as well as renewed contracts It applies automatically when group insurance contracts are renewed However each treatment has a sub-limit under policy These sub-limits differ from one policy to another This must be checked sometime it is 100 % of sum assured and sometimes it is 25% to 50% of sum assured.
Top tips to avoid health insurance claim rejection
Basic guidelines to be followed while opting for these modern methods to avoid any claim rejection as mentioned below:-
- These are all planned procedures hence one should take prior approval by submitting an estimate Doctor should specify the treatment duration complete package cost and need of admission or daycare.
- Read the terms and conditions of policy where these treatments may have sub-limits for example 50% of sum assured or ask the sub-limits by calling your insurer.
- As these can be under daycare hence choose a hospital with a daycare facility Fill documents for daycare get admitted and then ask for procedure Do not try under OPD unless your Policy allows treatment under OPD with no sub-limits of expenses.
So go ahead plan treatment with new-age technology