The wordings in your mediclaim form is crucial for acceptance or rejection
By Abhilasha Ojha
Two months ago, on a Delhi winter morning, I nearly collapsed. I was in my office, waiting to meet a deadline, when I felt like a speeding truck had run over my abdomen, crushing me with its weight and leading to unbearable pain. I cried, tears rolling down my cheeks, and clutched my abdomen with my hands and prayed… for death so that I could be out of this misery. I reached home, abandoning my work, popped a pain-killer, took a hot water bag and slept off for four hours. By evening, I was better.
An ultrasound showed mammoth fibroids, endometriotic cysts in both ovaries and a uterus that needed to be checked thoroughly. My gynecologist said that I would require three surgeries i.e. hysteroscopy, myomectomy and laparoscopy, which was anyway the first step to check the damage in my body. The amount to be shelled out: `1.5 lakh.
I flashed a smile when my doctor told me the amount. I said,“I have mediclaim.” But he said: “Don’t bank on it. This procedure is covered under ‘infertility’, which is termed as a ‘lifestyle disorder’. It is, therefore, not covered under mediclaim.” When I told him that my issue was unbearable pain, which I could live with earlier, but not now, I was advised by him not to even mention the pain I had earlier. “They (Third Party Administration or TPA) will not entertain you at all then,” he said.
My doctor said medical insurance guidelines were archaic as there was no provision for women suffering from fibroids and other gynecological problems. With my surgery planned almost like an emergency, I quickly spoke to my medical insurance agent, who asked me to directly get in touch with the medical insurance company.
Here’s what the doctor said:
“Madam, you have children?”
“No.”
“But you are married for seven years, so this surgery is to have children and we don’t cover infertility.”
“No, sir. My surgery is for me to no longer have this excruciating pain and to lead a quality life. It is not for having children. And even if it was, is infertility such a bad word?”
“Arre, madam, but your doctor should write that it is for pain and not for infertility.”
This was barely a week before my surgery and my doctor had to book the operation theatre in a leading hospital. What’s more, I had asked him to write out the letter three times for the TPA.
“Sir, why is infertility not covered under mediclaim? I pay my premium regularly so I can benefit monetarily when I need the money the most. And now you tell me this is covered, that is not covered.”
“Guidelines, madam. What can we do?”
One day before my surgery, I got lucky. My medical insurance company gave me the green signal—I got the mediclaim! My friends, on the other hand, never got any claim as the word “infertility” got their claim rejected. They never bothered to follow up, sick as they were after the experience. In my case, I told my gynecologist exactly what to write. It sounded rude, untrue, demeaning: “Surgery for pain, not infertility. The patient clearly says she does not want children.”