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Insurance Article

Authorities Rule That Your Medical Insurance Must Cover Pre-Op Expenses as Well

January 08 2019

Health insurers cannot reject your claim for pre-operational and non-medical expenses even if its incurred 30 days before the surgery

The state consumer forum recently ordered that Mediclaim insurance policies must also cover all the pre-surgery expenses such as doctor consultation fees and medical tests, etc. It means that if you pay from your pocket for these expenses, you are entitled to get a reimbursement from the health insurance company.

The commission gave these orders after reprimanding a public insurance company for rejecting a reimbursement claim made by a resident of Mumbai, V. Sridhar. It pertained to the insurer rejecting his reimbursement claim for pre-surgery and non-medical expenses, such as gloves for medical use, incurred for the knee surgery of his son.

In his complaint, Sridhar said that the Mediclaim policy covered his son, wife and himself for a sum of up to ₹1 lakh and when he submitted his claim, the insurer agreed to pay only ₹30,856, but refused to compensate for pre-operation and non-medical expenses.

The forum also specified that expenses incurred on consultation and pre-surgery tests cannot be refused just because the policyholder had undergone them 30 days before the surgery. “The MRI test was necessary before surgery. Under these circumstances, the insurer could not have refused to pay incidental and consequential expenses merely on the grounds that it was not done within 30 days,” the commission noted.

The consumer body also said that when the policy’s assured sum was ₹1 lakh and the claim made is for a much lesser amount, and was supported by documents, the insurance company should have allowed it as it included fees for surgery and consultation charges, MRI charges, and gloves, etc., among other medical equipment.

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