Tpa denying cnvm retina treatment claim.

Mohammed Vaid (Querist) 21 December 2020 This query is : Resolved
Hi,
I am working with TATA Consultancy Services Limited, and we have corporate mediclaim policy.
Yesterday my Eye Dr. advised me to undergo CNVM retina treatment, where he will give me Anti-VEGF injections inside my eyes as I am suffering from bleeding problem on my Retina.
As per the doctor this needs to be treated urgently without any delay and doesn't requires hospitalization, otherwise it can lead to complete blindness. I just have to visit him and he will give injection into my eyes and will let me off, the whole procedure would be of 10 mins.
He informed me that this treatment is covered under Mediclaim policies and as per him this is approved by IRDA too.
I raised this query to our company's TPA "Medi Assist Insurance TPA Pvt. Ltd." and they are denying to pay for this stating that it is not covered in policy.

I need help on this. Can you please advise is this covered as per the law or not.
If they don't agree to pay, what rights do I have to claim for the same and to which authority should I plea.

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Quick Summary

An individual is seeking help after their TPA, Medi Assist, denied a claim for urgent CNVM retina treatment involving Anti-VEGF injections. The doctor stressed the urgency to prevent blindness and stated the treatment doesn't require hospitalisation. The policyholder needs to understand their rights and whether the treatment is legally covered, especially since TPAs often require hospitalisation for claims.

Rajendra K Goyal (Expert) 21 December 2020
Go through the terms of policy.

Generally where patient is not admitted, claim is not reimbursed.

If claim was covered under the policy and claim was wrongly rejected, move to consumer forum.
,

kavksatyanarayana (Expert) 21 December 2020
to my best known, a patient should be admitted into Hospital at least for 24 hours to avail of the medical claim. And Companies may reduce the health insurance cover at their discretion.

Advocate Bhartesh goyal (Expert) 22 December 2020
Patient who admits in hospital at least for 24 hours for treatment of a desease or operation is entitled to get the claim except exclusion of some disease and operations mentioned in exclusion clause of policy.

P. Venu (Expert) 22 December 2020
Any suggestion depends upon the terms and conditions.

Dr J C Vashista (Expert) 24 December 2020
Send a copy of the mediclaim policy for consideration and professional advise.

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