Is there any ceiling for sanction the bill of total knee replacement (both the knees)--insurance co is NATIONAL INSURANCE CO AND TPA IS HEALTH INSURANCE TPA OF INDIA LTD-RETIRED OFFICER OF CENBTRAL BANK OF INDIA

[T.R. Nimade]

Is there any ceiling for sanction the bill of  total knee replacement (both the knees)--insurance co is NATIONAL INSURANCE CO AND TPA IS HEALTH INSURANCE TPA OF INDIA LTD-RETIRED OFFICER OF CENTRAL BANK OF INDIA AND POLICY IS COVERED BY IBA PLAN FOR NATIONALISED BANK

RESPECTED  Sir,                                                                                                 Date:27/03/22

Please enlighten me on the above medi claim policy for the year 2021-2022 FOR NATIONALISED RETIRED BANK EMPLOYEES/OFFICERS which is covered under IBA PLAN.

 

A surgery is to be carried out for my wife for both the legs (KNEE REPLACEMENT  FOR BOTH THE LEGS TKR) who is a Sr citizen.

 

Different hospitals have their packages to cover the above operations under cashless scheme and  SOME OF THE HOSPITALS ARE NOT APPROVED UNDER CASHLESS SCHEME BUT PERFORM THE OPERATION ON first payment  method to hospitals and thereafter  obtain the REIMBURSEMENT  from TPA/INSURANCE CO.

 

Sir,Please guide me if there is any ceiling of maximum sanction for above surgery in a cashless facility or the maximum amount of sanction if the surgery is performed in a non-approval hospital of a cashless facility.

Your valuable guidance in the matter will be highly appreciated and certainly relieve my burden in the matter.

Thanking you,

With kind regards

T R Nimade

09827009547

[subrata kumar sil]

Sir, recently my wife has gone TKR in Kolkata. Avoid PPN hospitals since their payment capacity i s restricted under Cash less facility. In case it is done in PPN hospitals please keep all bills, cash memos, reports, doctor's visit charges etc are on ly REIMBURSABLE against production of documents. There also TPA is playing role of decider and not the facilitator, trying to impose their own thoughts defying all norms and rules.

Thus it is better to search for Network hospital for cash less facility. Before choosing hospital consult doctor/ surgeon and also hospital concerned for detail of expenses may occur. Post hospitalisation cost for service of Physiotherapist is also reimbursable.Unfortunately I compelled to choose PPN and still suffering for release of bill payment for three months.Regards- Subrata Kumar Sil BOI retiree- 9830260314

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[subrata kumar sil]

Further there is no capping in expenses for TKR but within your sum insured and top up. - S.K.Sil

[Mohan Revathi]

There is no cap for TKR.

Check with the surgeon /hospital  who  /  from where u r going to take the surgery for a rough estimate of expenses.

If the room rent exceeds Rs.5000/- u may face proportionate cur in other hospital expenses like nursing charges, operation theater fees, surgeon's fees anaesthetist fees etc. Ensure that room rent is within ur entitlement.

U r elegible for reimbursement of cost of Walker and post operative physiotherapist care.

Ambulance / taxi fare  for admission/ discharge from hospital for travel from home and back ( each one trip only,) can be claimed.

My spouse under went the said surgery for both legs in Dec 2020 and the cost was Rs.4.25 lakhs and full amount was reimbursed as I was having insured amount of Rs.4 +Rs.5 lakhs.

Please note to get the cover with serial no for the equipments used by the hospital ( I mean knee joints) and this has to be submitted along with your claim papers .

Remember walking and climbing of staircase is a must for recovery.  Failure to do the exercises prescribed by the surgeon / physiotherapist will not yield fruits of surgery.

Post surgery of three months patient will be experiencing intolerable pain which will gradually reduce during this period.  After that the patient will not feel even slightest symptom of pain and will have trouble free walk for two decades as told by Drs.

My spouse is now happy and is able to do namaskar, sit in the floor and what not.

All the best.

Regards,

R. Mohan

To view this discussion on the web visit https://groups.google.com/d/msgid/bankpensioner/750816147.893248.1648446869402%40mail.yahoo.com.

[subrata kumar sil]

Sincere thanks to Mr Mohan, Absolutely right what you said. I am a BOI retiree and TPA is Raksha TPA. Their handling of claims is not at all satisfactory.First original documents sent is lost although Post office confirmed delivery on the next day. After putting complaint with NIC grievance officer claim processed with declining some expenses like cost of walker, dressing charges etc. So please put pressure with TPA to get full admissible expenses. Thanks - S.K.Sil

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[Mohan Revathi]

There is a specific mention in the policy that cost of Walker will be reimbursed.

In my case also they initially rejected. Then on my pointing out the provisions in the policy they reimbursed.

Go through the policy document and show this provision.  They will reimburse.  If not take with NIC.

Thanks & regards,

R. Mohan

Canbank Retiree

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[T.R. Nimade]

Dear R Mohan Sir,                                                                         Date:31/03/2022

Thank you very much sir for your detailed guidance  about the procedure, precautions to be observed while submitting the bill and the lifestyle and exercise after discharge from the hospital which will play an important role for the healthy and trouble free living of my spouse.

Thanking you,

With kind regards

T R Nimade

09827009547

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