Claim rejection? Knee replacement surgery

My Mom is 67 and she is to undergo a knee replacement surgery next month. She had met with an accident 10 years ago and had her leg fractured (steel plate inside) below the knee. The knee replacement is not at all related to the accident as she started to get pain only late last year. This week, we went to get pre-auth done by ICICI LOMBARD and the hospital staff expressed a concern the claim may be rejected due to the accident. Is it true? The doctor said clearly he'll be mentioning in the report that both are totally un-related.

Since the insurance co. will see X-ray reports, they'll get to see the steel plate and hence know about the accident. The hosp staff suggested that we mention that the accident happened just 5 years ago (my policy is in force since 2007) and NOT tell about the accident being so old because I was not covered then. I'm confused as I thought we 'll stand a better chance to say the accident happened 10 years ago which will make our case stronger to say knee repl is not related to the accident. After the accident, there was an FIR and she had received some insurance amount as well. Should I mention it all as it is ? OR should I say it just happened 5 years back with no mention of FIR etc ...?

In case of a dispute, we'll be better off having mentioned the true story....

In any case, I understand we have to mention that the pain in the knee is very recent. Please advice

Knee Replacement is a costly operation, so will be reviewed by the doctor panel of the insurance company. I believe that they are as good as your current doctor to find out, when accident happen and steel rod etc. (or may go for further tests to find out).

Why this new problem happen? Is it relate with the old problem? Only doctors can say.

Pre-existing disease are covered after 4-5 years of the policy. So I feel it's better to declare the true state.

Thanks Take. You mean to say any pre-existing diseases are covered after 4-5 loyal years with one insurance co. ? Wow thats cool ....

Me and my doctor feels its natural wear and tear and not cos of the accident (accident caused damage to right leg only; knee replacment is for both legs). But yea, hope they feel the same too :)

One more query - If rejected, how easy is it to dispute? IS it online ? Any quick links to read up on the procedures , TPA etc ?

Thanks ....

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Originally Posted by abraham

Thanks Take. You mean to say any pre-existing diseases are covered after 4-5 loyal years with one insurance co. ? Wow thats cool ....

Me and my doctor feels its natural wear and tear and not cos of the accident (accident caused damage to right leg only; knee replacment is for both legs). But yea, hope they feel the same too :)

One more query - If rejected, how easy is it to dispute? IS it online ? Any quick links to read up on the procedures , TPA etc ?

Thanks ....

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Read more about - When Pre-existing disease will be covered?

Claim not paid or rejected follow below procedure -
Approach Insurer First in writing > (No Result) Approach IRDA > (No Result) Approach Ombudsmen/Consumer Forum

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Originally Posted by abraham

Query - If rejected, how easy is it to dispute? IS it online ? Any quick links to read up on the procedures , TPA etc ?

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It all depend on case to case. If your case is strong then your will get claim but regular followup is necessary. Check following IRDA Link for read up.

If Your Claim is Denied
Start by reviewing your paperwork file. Then call your Insurer's customer service. Clear your doubts on claim and ask why the claim is rejected. Be sure to take notes on all phone conversations, including the date and time of the call, the names of the people you talk to and what was discussed.

File an Appeal with Insurer
If speaking with a customer service representative does not work, you may have to escalate to a formal written appeal. You need to provide all the information in writing with supporting documents including copies of bills, hospital address (where treatment is taken), TPA deatils if any and your physician's statement about why your treatment was or will be necessary.

Submit following Documents with your Appeal
1- Your health insurance policy
2- Copies of denial letters from insurer
3- Copies of any correspondence between you and your Insurer, or between your hospital (such as your doctor or lab or TPA)
4- Copies of claim form

If nothing happens follow >take's procedure -

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Approach Insurer First in writing > (No Result) Approach IRDA > (No Result) Approach Ombudsmen/Consumer Forum

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Yes, you can file your complaints online with IRDA's IGMS.
Link to IGMS - Link

Also read attached excellent Health Insurance Handbook by IRDA.

Thank you both. So i'll stick to the true story of the accident (10 years ago) with all the details so that if needed, I can dispute. If I put in anything else, I wont be in a good position to dispute.

Hope the need doesnt arise. Thanks again. Will keep you posted in first week of May

I went through the clauses on pre-existing diseases. One last clarification:

Is it a pre-requisite that the pre-existing condition (in my mom's case - the accident) occured while the insurance was in force?
Or
It doesnt matter that the accident happened before insurance was taken ?

You need to disclose any medical condition in the proposal form, in both the above cases. Whether it is pre-existing or happened during the period of your health insurance policy.

Hey all - Got a pre-auth for 2 Lacs for my Mom today. No questions asked. Had presented the facts as it is with accident details, FIR, etc ... I assume there will not be an issue now. Or is there a chance it can be cancelled at the time of surgery on any basis? Is that a possibility ?

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Originally Posted by abraham

Hey all - Got a pre-auth for 2 Lacs for my Mom today. No questions asked. Had presented the facts as it is with accident details, FIR, etc ... I assume there will not be an issue now. Or is there a chance it can be cancelled at the time of surgery on any basis? Is that a possibility ?

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Are you hiding something?
Or doing some wrong doing with the claim?

If all OK. Then why the insurance company deny the claim.

well, i think this forum is to clarify things from the experts. I aint hiding anything; was just asking if a claim can be denied after pre-auth? Does it happen ever? etc .... IF u read up i have already stated I went ahead with all the facts as it is .... It isnt everyday that I claim from a Medical Insurer - so asking / clarifying ...

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Originally Posted by abraham

well, i think this forum is to clarify things from the experts. I aint hiding anything; was just asking if a claim can be denied after pre-auth? Does it happen ever? etc .... IF u read up i have already stated I went ahead with all the facts as it is .... It isnt everyday that I claim from a Medical Insurer - so asking / clarifying ...

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Yes, its possible that a claim can be denied after a pre-authorization. Pre-authorization is not a guarantee. Claims can only be determined eligible/ineligible at the time it is processed, and may be denied even after a pre-authorization or pre-determination is issued.

Yes Abraham, It can also be cancelled after approval but I hope it would not be in your case but stick to your points, what ever you mentioned while Pre-Auth because when a surveyar will come to hospital then he/she would note down your statement. So, be careful and stick on your words but once your mother got discharge from the hospital then nothing to worry. Describe each and every point to your mother because company representative will approach to your mom