In cashless mediclaim, act on time to avoid hassles

Sanjeev Sharma, a middle-aged man, who maintains a healthy lifestyle, one day felt a severe pain in his abdomen.

Immediately, he was rushed to a nearby hospital, where he was admitted and kept under observation for a day. Doctors reported that the patient has kidney stones, which can be treated by medicine, however, he needs to be kept under observation for 24 hours.

As per the doctor’s advice, he spent the night in the hospital and started taking medication prescribed by the doctor.

His wife paid the hospital bills and other expenses related to the hospitalisation, but later when they registered a claim with the insurance company, the claim was not accepted. The insurance company said that hospitalisation was not necessary at all for his condition.

Later on, when a complaint was registered with the insurance ombudsman, the decision came in favour of the policyholder, based on the doctor’s report, which said that the patient needed medical supervision.

Situations like these put additional and unwarranted pressure on policyholders and their family members.

Emergency definition: Insurance companies generally categorise emergencies as medical and surgical. Surgical emergencies are generally accident cases and trauma. In addition, surgical emergency may include other surgical problems like acute abdominal pain or dislocation of a joint and any other problem where an emergency surgery is required to stabilise the patient. For example, rupture of an infected appendix.

Medical emergencies commonly include heart-related emergencies, brain stroke, asthma, epilepsy, seizures, complications from high blood pressure or blood sugar.

“Accidental hospitalisation is covered under all health insurance policies. There is generally no waiting period for accident cases. Hence, there is very little chance of authorisation being denied in the presence of a valid policy and insurance limit available,” said Sanjay Datta, head of underwriting and claims of ICICI Lombard General Insurance.

The normal processing time for cashless treatment for non-emergency cases is three to four hours from the time of receipt of complete information from the hospital. But to expedite the entire process, insurers and third-party administrators (TPAs) request the network hospitals to inform them as soon as a patient is admitted.

The contact number of TPAs and helpline number of insurers are mentioned on policy documents and the policyholder needs to coordinate with the hospital to have the details sent to the TPA for authorisation of cashless service. On discharge, the policyholder needs to verify and sign the bills and pay for the items that are not covered under the health policy. The policy document contains all the details about the expenses that are payable under the policy. The original discharge summary and other investigation reports should be handed over to the hospital. However, a policyholder must retain a copy for records.

In case a policyholder goes to a non-network hospital (where policyholder cannot avail cashless facility) for an emergency situation, the policyholder has to register a claim with the TPA within seven days of discharge.

For emergency conditions, policyholders are asked to pay a nominal deposit as per the norms of the treating hospital, which may differ from one hospital to another.

'70s SoCal singer-songwriter is back , catch him while you can

"It's kind of like being kicked by a giant mule," said J.D. Souther last week from his wheat farm outside Nashville.

A week earlier, the 65-year-old co-architect of the Southern California '70s country-rock sound had been happily touring, promoting his fine new album, "Natural History," when he was struck down by kidney stones.

Souther didn't waste any time feeling sorry for himself. He was scheduled to appear in Seattle on Sunday, as planned.

That's good to hear, since Souther has been known to disappear. The last time, it was for 25 years.

After writing multiple hits back in the '70s — "Best of My Love" and "New Kid in Town" for the Eagles and "Faithless Love" and "Silver Blue" for onetime girlfriend Linda Ronstadt — he went on hiatus for a quarter century.

Fed up with the music scene, and swimming in a stream of royalties, he built a dream house in the Hollywood Hills, rescued a couple of dogs, rode horseback on pack trips and skied in New Zealand and Colorado. An admirer of the late Northwest poet William Stafford and a friend of beat writer and publisher Lawrence Ferlinghetti, Souther also wrote poetry, though he's reluctant to publish his verses.

"Absent the musical landscape, the bar is a little bit higher," he explained.

This is the man who wrote (in "I'll Be Here at Closing Time"), "Is that a ring on your finger / Or just a thin and fading line?" — which in two lines pretty handily conjures the image of a lonely man eyeing up a waitress. But it does sound better sung — certainly when he sings it.

It's on his latest album, which compiles 10 songs — including his own 1979 Roy Orbison-inspired hit, "You're Only Lonely" — in a minimalist, noir setting, featuring his pristine guitar, tenor voice (sharpened to pure crystal) and occasional solos by jazz players.

Souther came up playing jazz drums and saxophone in Amarillo, Texas, and, remarkably, never picked up a guitar till he was 22. When he did, he applied a jazz harmonic sense to it (like that weird repeated chord in "Silver Blue"). His 2008 comeback album, "If the World Was You," had a jazz twist, too.

But for Souther, it's a straight line from the Great American Songbook of Cole Porter and George Gershwin to latter-day standards written by James Taylor, Neil Young, Joni Mitchell and Souther himself.

"I can do 'Faithless Love' and follow it with Fats Waller," he said.

Which is apparently what he does in his show.

By all means, check him out before he decides to take another sabbatical.