Reimbursement claim in health insurance
5 months ago
My father got slipped and his waist got fractured. When we admitted him to hospital then doctor suggested for surgery. We went through surgery and treatment. Now when I sent expense documents to insurance company for reimbursement then they are asking for MLC/FIR whereas this was not done by hospital. Please suggest what should be done here?
A.Dear Client,
Every Hospital/Nursing home keeps an MLC register wherein accident/ assault/poisoning/ burn cases are registered by hospital authorities and submitted to the local police station. Fall and fracture of body parts is considered an accident and comes under the purview of Medico-Legal Cases. A medico-legal case should be registered by the treating Doctor of the hospital as soon as the patient is brought to the Hospital and admitted for necessary treatment. Under Section 39 of Cr.PC, the attending MO of the hospital is legally bound to inform the police about the arrival of an MLC. Any failure to report the occurrence of an MLC may invite prosecution of MO/Hospital under Sections 176 and/or 202 of I.P.C. An MLC is an important piece of document/evidence amongst others required by an Insurance Company to settle the claim made under a health insurance policy by the policyholder. So, when you are facing rejection of a claim by an Insurer for deficient service of the concerned hospital, you need to file a complaint against both the concerned Hospital and the Insurance Company over alleged deficiency in service under Sec.35 of the Consumer Protection Act, 2019 claiming the entire cost of treatment along with compensation for harassment before the Dist. Consumer Commission. The complaint must be filed within two years from the date of cause of action, i.e, the date of rejection/repudiation of claim by the Insurance Company. Reach out to an Advocate for guidance and steps.
Every Hospital/Nursing home keeps an MLC register wherein accident/ assault/poisoning/ burn cases are registered by hospital authorities and submitted to the local police station. Fall and fracture of body parts is considered an accident and comes under the purview of Medico-Legal Cases. A medico-legal case should be registered by the treating Doctor of the hospital as soon as the patient is brought to the Hospital and admitted for necessary treatment. Under Section 39 of Cr.PC, the attending MO of the hospital is legally bound to inform the police about the arrival of an MLC. Any failure to report the occurrence of an MLC may invite prosecution of MO/Hospital under Sections 176 and/or 202 of I.P.C. An MLC is an important piece of document/evidence amongst others required by an Insurance Company to settle the claim made under a health insurance policy by the policyholder. So, when you are facing rejection of a claim by an Insurer for deficient service of the concerned hospital, you need to file a complaint against both the concerned Hospital and the Insurance Company over alleged deficiency in service under Sec.35 of the Consumer Protection Act, 2019 claiming the entire cost of treatment along with compensation for harassment before the Dist. Consumer Commission. The complaint must be filed within two years from the date of cause of action, i.e, the date of rejection/repudiation of claim by the Insurance Company. Reach out to an Advocate for guidance and steps.
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A.Dear Client,
Firstly, carefully review your insurance policy to understand the terms and conditions, including any requirements for filing claims and any documents that may be necessary for reimbursement. Make sure you're following the policy guidelines. Secondly, reach out to the hospital where your father was treated and ask if they can provide any documentation related to the incident. They may be able to provide a letter or medical report that describes the circumstances of your father's injury. Further, talk to your insurance company and explain the situation. Ask for clarification on why they are requesting an MLC/FIR. In some cases, they may accept alternative documentation if it adequately explains the incident.
Firstly, carefully review your insurance policy to understand the terms and conditions, including any requirements for filing claims and any documents that may be necessary for reimbursement. Make sure you're following the policy guidelines. Secondly, reach out to the hospital where your father was treated and ask if they can provide any documentation related to the incident. They may be able to provide a letter or medical report that describes the circumstances of your father's injury. Further, talk to your insurance company and explain the situation. Ask for clarification on why they are requesting an MLC/FIR. In some cases, they may accept alternative documentation if it adequately explains the incident.
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