Nayan Eye Centre
Pvt. Ltd.
Enhancing Vision ..... Enriching Lives
Comprehensive & Personalized Eye Care
46 B Garcha Road. Kolkata 700019.
Enter Garcha Road Opp. MUKTI WORLD - TANISHQ.
Keep Gariahat Tram Depot to your left.
(Garcha Road is one traffic signal south of Ballygunge Phari)
Ph: 9830159838 (9 AM to 6 PM, Mon to Sat)
MEDICLAIM
Please inform the Reception / Doctor before consultation and at Operation booking if you have a Mediclaim / Reimbursement facility so that:
⦁ Correct Particulars of Name, age and address are noted to facilitate your claim.
⦁ You are informed of the correct Protocol.
OUR MEDICLAIM ASSISTANCE: Our Team will guide you to get the maximum benefit out of your Mediclaim Policy. All Mediclaim policies are not the same. You put in your hard earned money for years for a policy so that you can avail of quality medical care when you need it. Do not let your ignorance, your Agents laziness, fine print, Insurance Company or TPA (Third party administrator) come in the way of you realizing the maximum out of your policy. Attention to small details & little planning can help you save a lot. We can also assist you in filling up your forms.
MEDICLAIM: Facts you must know
Multifocal IOLs & Extended Depth of Focus IOLs are Payable
Times of India, 4th February, 2019.
Woman wins claim in cataract surgery case
In a first ever, an insurance company has been ordered to reimburse the claim for a cataract surgery with multifo- cal lens implant. Till now, in- surance companies used to refuse to pay for multifocal lens on the pretext that only reasonable expenses for a standard intra-ocular lens are payable.
Laila Baria had taken a mediclaim policy from United India Insurance in January 1997 and kept renewing it. In June 2014, she underwent a cataract surgery of the left eye with multifocal lens implant at Banaji Eye Centre for Rs 1.8 lakh. The insurance company paid Rs25,000. In July 2014, she underwent a similar surgery for the right eye for which she was again charged Rs1.8 lakh, but this time the company reimbursed R$40,000.
Aggrieved her entire claim was not paid, Baria filed a consumer complaint. She ar- gued claims were being set- tled in an arbitrary manner.
The insurance company defended itself, saying it was li- able to pay only “customary and reasonable expenses”, and that the claim had been settled in accordance with In- surance Regulatory and De- velopment Authority (IRDA) regulations.
The Forum concluded a consumer who has paid the medi- cal bill would have to be reim- bursed the entire amount, un- less the policy has certain conditions.
On November 20, 2018, the Forum ordered the company to pay the balance claim amount along with 6% inter- est. In addition, compensation of Rs10,000 and costs of Rs5,000 were also awarded. The insurance company com- plied and paid Baria Rs3,84,825. Conclusion: Claim for multifocal lens is payable. Claims under different poli- cies can be clubbed together to avoid multiplicity of litigation.
(The author is a consumer ac- tivist and has won the Govt. of India’s National Youth Award for Consumer Protection. His email is jehangir.gai.colum- nist@outlook.in)
Don’t fix amount for cataract surgery, pay full claim – Court
Times of India, 10th December, 2020.
Surat: Valsad District Consumer Dispute Redressal Commission (VDCDRC) has ordered an insurance company to reimburse the full claim amount for a cataract operation to a Valsad resident instead of the amount fixed for the surgery by the insurance firm. According to the case details, Rajiv Shah, a resident of Rajput Complex in Valsad town, had purchased a health insurance policy with Rs 2.5 lakh sum insured from The Oriental Insurance Co Ltd in April 2018.
On December 28, 2018, Shah underwent a cataract operation at Amardeep Hospital in Valsad and was admitted as an indoor patient. Later, he claimed reimbursement of Rs 45,632 as medical cost before the insurance company. But Shah received only Rs 24,000.
The insurance company deducted Rs 21,632, on the grounds that under the policy only Rs 24,000 was payable to the policyholder for a cataract operation.
Shah filed a case against the insurance company before VDCDRC in February 2019 seeking full payment for his medical expanses.
While deciding the matter, the consumer court observed that the insurance company has not shown under which terms and conditions Rs 21,632 was deducted from the claim amount.
“Moreover, the expense incurred is related to medical services and therefore the complainant is entitled to get full claim amount against the expense incurred by him. The insurance company will pay Rs 21,632 with 7.5% effective from February 24, 2019,” the consumer court observed.
The court also ordered the firm to pay additional Rs 2,500 for legal fees, mental and physical stress experienced by the complaint.
Claim Amount for Cataract Cannot be Fixed – Vadodara Court
Times of India, 23rd September, 2021
VADODARA: A uniform amount for cataract surgeries cannot be assumed or fixed by insurance companies while dealing with claims of insured persons, a court here ruled last week.
The Vadodara District Consumer Disputes Redressal Forum turned down the claim of Oriental Insurance Company Ltd and third-party administrator MD India Health Insurance TPA Pvt Ltd’s claim that Rs 24,000 is a reasonable amount for cataract surgery on one eye.
The forum was hearing a complaint filed by a resident of Harni Warasia Ring Road, Dr TJ Prajapati, who had undergone cataract surgery for his left eye in November 2019. Prajapati incurred an expense of Rs 42,000 for the surgery, but the insurance company and the TPA paid just Rs 24,000.
Court stated that ophthalmologists use imported lenses and expensive materials to ensure that cataract surgery is done properly so that the patient’s eye and vision remain healthy. “In such circumstances, the operation expenses may be more. It all depends on which expert is doing the surgery and is using which type of lens and there is no condition in the policy that a specific type of lens can only be used,” the forum stated in the judgment.
During the hearing, the opponents’ lawyer submitted that the remaining amount of Rs 18,000 was deducted as per the cataract limit of the policy. It was argued that as per the policy of the insurance company Rs 24,000 can only be considered as reasonable and customary expense for cataract surgery and the expense of Rs 42,000 incurred by Prajapati is excessive.
Opposing the insurance company and TPA’s argument, Prajapati’s lawyer told the court that the money was deducted wrongly because Prajapati was never told under which clause of the policy it was done nor any such clause is stated in the policy which he had bought in 2010. The court’s attention was also drawn to the fact that the TPA had deducted the amount and the insurance company did not write any letter to Prajapati informing him that money has been deducted and under which clause.
The court upheld the arguments and also went on to note that the insurance company and TPA could not support its claim that Rs 24,000 is a reasonable amount by submitting any expert doctor’s opinion.
Insurance company cannot refuse claims stating ‘Expenses not customary & reasonable’
Insurer can’t decide on medical expenses limit
Times of India, 20th June, 2023
VADODARA: In an important verdict, a consumer forum in Vadodara recently ruled that insurance firms can’t decide which expense isn’t necessary for medical treatment and how much maximum amount can be paid for it. The observation was made while ordering an insurance firm to pay the full medical bill of Rs 1.64 lakh to complainant Mayur Parmar for cataract surgery.
Parmar, 61, had undergone cataract surgery for both eyes in December 2022 and January this year and spent Rs 1.64 lakh on the treatment. He claimed insurance money from Oriental Insurance Company Ltd for the same. But the insurance firm partially approved his claim and agreed to pay Rs 49,000. The complainant said that the insurer refused to pay the full amount on the grounds that the expense of the cataract surgery wasn’t customary and reasonable.
In February this year, Parmar filed a case against Oriental Insurance Company Ltd in the Vadodara District Consumer Disputes Redressal Commission (additional) and demanded reimbursement of full medical expenses. He said in his complaint that the insurer wrongly interpreted the policy’s terms and partially rejected his claim.
After hearing both sides, the consumer forum observed that the policy doesn’t mention what exactly reasonable and customary charge means and how the company has interpreted it. “The medical treatment fee varies in every hospital and as per the doctor. The fee of an expert doctor is usually high. The insurance firm can’t decide which expense wasn’t necessary during the treatment,” the forum observed.
Also, the insurer can’t decide how much charge (medical expenses) the complainant is entitled to get,” the forum said and added that the insurance firm can’t decide on the customary charge too. “Reasonable charge means the expenses done for the necessary treatment and hence it is not an excessive expense. The insurance firm cannot decide on how much and what kind of expense the doctor can do during treatment,” the forum observed.
“Cataract surgery is a common surgery but the medical expense depends on which doctor does the surgery and what kind of lens are used. Terming the partial claim rejection unreasonable, the forum ordered the insurer to pay Parmar the remaining Rs 1.15 lakh with 9% interest within two months from the date of the order.
The insurer has also been ordered to pay Rs 5,000 each towards mental harassment and the legal cost.
Claim for Cataract Operation is generally not allowed in the First 2 Years of Policy. So you must have paid the 3rd Premium to claim for cataract operation. Certain emergencies may be allowed.
You are entitled to reimbursement of all expenses incurred towards the operation from 30 days prior to the date of surgery till 60 days. It is advisable to submit the intimation & retain an acknowledgement of the same. Submit a copy (not original) of the Prescription & Preoperative Instructions.
Please preserve all receipts towards consultation, investigations, medicines, consumables, nursing home etc.
24 hrs stay at Nursing home / Hospital for Cataract operation is not mandatory – Day care stay is allowed: Your agent is often misinformed – Please read the policy document. If you insist, you are welcome to stay for 24 hrs and pay additional charges.
Please make a photocopy of the entire set of documents before you submit your originals for the claim.
Individualized & Personalized Care is better delivered in Smaller set ups: Eye Surgery is mostly Short stay Day Care Surgery, requiring easy admission & discharge procedures, transparent billing & Personalized postoperative care. These are often not possible at big Corporate Multispecialty hospitals. The facilities for surgery and care are at par or better at Smaller Units but the red tape and protocol is less painful for the patient and doctor. You get more value for Money, because nothing is spent on unnecessary overheads & facilitator charges.
Disclaimer: The above is only meant to serve as a guideline to assist in patient care and is not a legal document. The facility, Doctors or staff will not be responsible for any damages arising out of any errors of omission or commission in this document.
Please let us know if we can assist you in any other way.
Mediclaim & Intra vitreal Injections
IRDAI/HLT/REG/CIR/193/07/2020 dated 22nd July, 2020 (Full Document Link ), (Chapter II.1(g) & V.1(F) Link)
Herein, it is explicitly stated that Intra Vitreal Injections shall not be excluded in the health insurance policy contracts.
Chapter II. 1(g) (Page 95): Age Related Macular Degeneration (ARMD) is not an Exclusion allowed in Health Policies
Chapter V. 1(F) (Page 105): Insurers shall ensure that the policyholders are not denied availability of health insurance coverage to Modern Treatment Methods and procedures like Intra vitreal injections, and it shall not be excluded in the health insurance policy contracts.
Please read this Article:
Narayanan R, Sengupta S. Insurance coverage for intravitreal injections in India-The road ahead. Indian J Ophthalmol. 2021 May;69(5):1027-1028. doi: 10.4103/ijo.IJO_738_21. PMID: 33913825; PMCID: PMC8186598. (Link)
CASHLESS or UPFRONT Payment for MEDICLAIM
We prefer upfront payment by you and we will assist you in every possible way so that you can get the best out of your policy. Bring your Policy documents along and we will assist you with the paper work. If your Policy is in order & fully paid up we can assure you of flawless paperwork & full reimbursement of your claim. It is upfront payment and submitting claim for reimbursement which gives you maximum value for your money. Maybe, you’ll have to wait for couple of months to get your claim, but you are the gainer in the long run.
Please note that Insurance Companies / TPA’s have imposed a blanket ceiling on Cashless Cataract Surgery at
Preferred Provider Network (PPN) Hospitals.
What it means is that if you avail of Cashless Mediclaim for Cataract Surgery in any of the PPN Hospitals you will have to abide by the ceiling even if your Policy entitles you to more.
Cashless Mediclaim ceilings may be much lower than what your policy entitles you. If you choose to restrict yourself to this ceiling – you are probably compromising on the quality of IOL or care, and not getting what is due to you as per your policy. You may choose to restrict your claim to the approved amount or pay the difference and not be reimbursed for this amount.
On the contrary, you may choose to make a cash payment and get operated at a non PPN Hospital / Regd. Nursing Home, and you will be reimbursed to the full extent entitled by your Policy.
No Free Lunch: On the face of it, it may appear that cashless Mediclaim is safe because you don’t have to spend from your pocket, but you are probably being denied quality care which you have been paying premium for. You may not have to spend upfront for your eye surgery, but do your get to choose your surgeon or your IOL? So pause and think before you decide.
Disclaimer: The above is only meant to serve as a guideline to assist in patient care and is not a legal document. The facility, Doctors or staff will not be responsible for any damages arising out of any errors of omission or commission in this document.