Summary
A family was admitted at a Care Health network hospital in Indiranagar. The hospital submitted pre-authorization for emergency surgery. Care Health denied it citing 'not medically necessary' — despite the treating surgeon's written recommendation. The family paid 6.2 lakh out of pocket. We filed for reimbursement with the surgeon's detailed justification and got full payout within 21 days.
How We Solved It
S Situation
Emergency appendectomy at Care Health's own network hospital. Pre-auth denied hours before surgery. Family forced to pay 6.2 lakh. Treating surgeon wrote detailed medical necessity letter.
T Task
Overturn the pre-authorization denial using the treating doctor's medical opinion. Secure full reimbursement for the out-of-pocket payment.
A Action
- 1. Obtained treating surgeon's detailed medical necessity letter with clinical findings
- 2. Collected hospital's pre-auth request and denial letter with timestamps
- 3. Cited IRDAI circular: network hospital denial ≠ claim denial
- 4. Filed reimbursement claim with complete bills and surgeon's letter
- 5. Followed up with GRO citing 'deficiency in service' for network hospital denial
R Result
Care Health approved full 6,20,000 reimbursement within 21 days. The approval acknowledged the network hospital's pre-auth denial was incorrect.
Lessons Learned
- Network hospital denial of cashless does NOT mean claim denial
- Treating doctor's medical opinion carries more weight than insurer's medical advisor
- IRDAI: insurer liable for network hospital's cashless denial
- Always get the surgeon's written justification for emergency procedures
"The hospital said 'cashless approved' then Care Health denied it right before surgery. We had to pay everything. Hari Sir told us it's the insurer's problem, not ours. Got every rupee back in 3 weeks."
— The hospital | Indiranagar, Bangalore
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