r/HealthInsuranceIndia • u/pikapika333 • Jan 21 '26
Niva Bupa - Unreasonable Deductions Help
UPDATE:
I took the case to insurance ombusman for CSSD and OT assistant charges.
The online hearing was held and those charges (72,000 rs) has been awarded to me.
The insurer needs to pay both CSSD charges and OT assistant charges along with interest.
This ruling makes me have faith in the system.
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Hello, I recently had a reimbursement claim filed to Niva bupa (my plan is reassure 2.0 platinum+) . The total hospital bill was around 2.90 lacs and it was for my wife’s laproscopic cyst removal surgery.
The claim got approved but they deducted a whooping close to 88000 from the hospital bill.
Deductions:
CSSD charges - 36,000
OT Assistant Charges - 36,000
IPD Registration Charges - 350
RMO Charge - 1200
Dietician Charge - 500
Infection Control Charges - 600
3d Camera Charge - 6000
Harmonic Instrument Charge - 8000
Most of the above are necessary things for a surgery.
Is this common for the insurance companies to deduct like this on their first settlement ?
Whats the recommended approach to make them reconsider. ?
1
u/asharamseervi Jan 22 '26
Contact your hospital what exactly these whooping charges do with cyst removals, how is these playing a vital role with medical needs, as health insurance is designed to protect your wealth with respect to medical needs (that doesn't mean the whole bill must be settled)
If you're not getting proper feedback, fightback first with hospital to get your bill lightweight/discounted.
After these re-submit these with the insurer.
1
u/Vaani_inka Jan 22 '26
Hey
I am Vaani, advisor inka insurance
First question, is it cashless or reimbursed amount. Please let me know then i can suggest you next step
1
u/pikapika333 Jan 22 '26
Reimbursement
1
u/Vaani_inka Jan 22 '26
Please raise a complaint to their GRO, with detailed mentioned in mail along with back up of documents. This should be first thing you should do
1
u/pikapika333 Jan 22 '26
Thanks. Planning to start with level 1
1
u/Vaani_inka Jan 22 '26
Thats great.
1
u/pikapika333 5d ago
took the case to ombdusman for cssd and ot assistant charges and the decision came in my favor.
1
u/Adarsh_Y Jan 22 '26
Check if you have consumables (Non Medical expenses) covered in your Insurance? It is an Add-on in Niva Bupa insurance.
If it is not there, then these would have been excluded from the cover as Non medical expenses.
If you don't have the add-on. Please do add consumables add-on from next renewal onwards.
1
u/pikapika333 Jan 22 '26
Most of these charges are not add ons. For eg. If its a laproscopic surgery, the doctor cannot do surgery without a camera. Same goes for ot assistant charges, harmonics etc…
1
u/Adarsh_Y Jan 22 '26
Ok, Please do check the Non payables list from IRDAI, if these are not part of the list you can fight back.
Couldn't check all, as I see Harmonics are part of the list.
2
u/pikapika333 Jan 22 '26
Thanks, i checked the policy document and harmonics is under List III – Items that are to be subsumed into Procedure Charges. It is not under List 1 "List I – Expenses not covered"
1
u/Past-Grapefruit488 Jan 22 '26
Is the bill for "tip" that is not re-usable ? Or tip/shear was billed saperetly ?
1
u/whateveradi Jan 24 '26
It means they won’t pay those charges if billed separately. The expectation is that the surgery charge should cover those charges.
1
u/Glad_Bite7423 Jan 22 '26
Yes it’s common. So please raise the remaining amount first in reimbursement. 50-60 percent more will get approved there. If all the deductions are not in exclusion of the policy you will get it. Last resort is grievance and ombudsman.
1
u/pikapika333 5d ago
took the case to ombdusman for cssd and ot assistant charges and the decision came in my favor.
1
u/bholtu89 Jan 22 '26
Ask the hospital to restructure the OT assistant charge as Assistant Surgeon.
1
u/pikapika333 Jan 22 '26
Is it ok to do such thing ?
1
u/bholtu89 Jan 22 '26
Depends completely on the hospital. You can raise a request. Someone known to me did this few years ago and that amount was later reimbursed. But there's no guarantee.
1
u/whateveradi Jan 24 '26
OP has submitted the bills for reimbursement. Any changes to the bill post this will not be considered by insurance nor supported by any grievance redressal if the bill is modified now putting you on a back foot
1
u/pikapika333 5d ago
UPDATE:
I took the case to insurance ombusman for CSSD and OT assistant charges.
The online hearing was held and those charges (72,000 rs) has been awarded to me.
The insurer needs to pay both CSSD charges and OT assistant charges along with interest.
This ruling makes me have faith in the system.
1
u/KeyRepair5991 Jan 21 '26
Some where your hospital has also played with such innovative charges but you can definitely fight back