Health Insurance Technical Manual

Cmd’s Message
I am glad to note that the Health Department at our Corporate Office has developed
the Second Health Insurance Technical Manual for the use of our underwriters,
Marketing Force and the Third Party Administrators.

Health Insurance is today the second largest line of business in the industry. We at
New India are proud to be the leaders in this line of business.

Especially in the field of Health Insurance customer expectations on speedy hassle

free settlement is very high. We at New India have an important role to play in
ensuring that our Customers get a fast and fair settlement of their claims.

I am confident that this Health Technical Manual will facilitate our endeavour for
Leadership and Beyond.

G SRINIVASAN
CHAIRMAN CUM MANAGING DIRECTOR

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Health Insurance Technical Manual

Foreword
We published our first Technical Manual in December 2012. It was well received
by our employees and the Third Party Administrators. Since the last publication
the Health Insurance and Health care industries have witnessed lot of changes.
It is time that these changes are addressed and our Manual updated.

Lot of efforts has gone into the preparation of this Manual, with inputs from our
employees, Doctors and also the experts from Third Party Administrators. Several
rounds of discussions were held among us, and the Manual has been compiled.

I thank all our Officers, Doctors and also the experts from the Third Party
Administrators for their valuable inputs. I also commend the efforts of the
Corporate Health Insurance team for their spirited efforts.

I welcome feedback from all users on the inputs in this Manual. In case any
corrections need to be made, they may kindly brought to the attention of
Dr. Wanda.

I hope this Manual will help us to serve our customers better.

SEGAR SAMPATHKUMAR
GENERAL MANAGER

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Contents
Medical Advancements____________________________________________________13-20
1. Peritoneal Ambulatory dialysis taken at home?.........................................................................13
2. Cyber knife:.................................................................................................................................................13
3. Stereotactic radio surgery....................................................................................................................13
4. Trigeminal neuralgia-gamma knife/cyber knife........................................................................14
5. Robotic surgeries.....................................................................................................................................15
6. Pacemaker battery replacement.......................................................................................................15
7. Enhanced External Counterpulsation (EECP).............................................................................15
8. Bio- absorbable stents...........................................................................................................................16
9. ‘Plasmapheresis’.......................................................................................................................................16
10. Dotatate Therapy for Neuro-Endocrine Tumours.....................................................................17
11. HIFU (High intensity focused ultrasound)/MR GUIDED Focused
Ultrasonographic Surgery(MRgFUS)...............................................................................................17
12. Artificial Pancreas system....................................................................................................................17
13. Coblation Assisted Tonsillectomy.....................................................................................................17
14. Laser Tonsillectomy................................................................................................................................17
15. Deep Brain Stimulation.........................................................................................................................17
16. LASER Assisted Hemorrhoidectomy...............................................................................................18
17. LASER Assisted Prostatectomy..........................................................................................................18
18. LASER Assisted End Arterectomy.....................................................................................................18
19. Retrograde Intra renal Surgery(RIRS)............................................................................................19
20. VAFT (Video Assisted fistula Treatment)......................................................................................19
21. Balloon Kyphoplasty...............................................................................................................................19
22. Balloon Sinuplasty...................................................................................................................................19
23. Single Incision Laparoscopic Surgery for abdominal surgeries..........................................20
24. Cardiology – CABG with MICS.............................................................................................................20
25. DENVAX is dendritic cell-based cancer immunotherapy........................................................20

Charges in Hospital Bill____________________________________________________21-25

26. Modified final hospital bill incorporating Surgeon/Anaesthetist /Visit Charges........21
27. Separate bills given by Anaesthetist and Surgeon exceeding the
Rs 10,000/- cash payment limit........................................................................................................21
28. Proportionate deductions on Surgeon and Anaesthetist bills..............................................21
29. Diet Charges...............................................................................................................................................21
30. Laparoscopic / Endoscopic surgeries: disposable items........................................................22
31. Charges for consumables......................................................................................................................22
32. Skin stapler payment..............................................................................................................................22
33. Stapler for stapler hemorrhoidectomy should be payable....................................................23
34. Hood- part of operation gown............................................................................................................23
35. Harmonic Ace, Harmonic Shears- are they payable?................................................................23
36. Surgical Appliances: There is no objective definition of an Operation Theatre............23
37. Monitor charges not mentioned in non-medical list provided by IRDA..........................24
38. Charges for RMO in room, pulse oxymeter or Intensivist charges in
ICU are seen in many hospital bills..................................................................................................24

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39. Should we consider HDU charges equivalent to ICU charges...............................................24

40. Charges for Trocar/ laser fiber to be considered.......................................................................25
41. Pro tack used in hernia payable?.......................................................................................................25
42. Cross matching charges.........................................................................................................................25
43. Diagnostic charges: Clause no. 2.4 vide Mediclaim Policy 2007..........................................25

Regulation and Legal Issues_______________________________________________26-29

44. In case the hospital is owned by an Ayurvedic Doctor............................................................26
45. Qualified Medical Practitioner is a family member...................................................................26
46. RMOs have AYUSH qualifications......................................................................................................26
47. Hospital Registration..............................................................................................................................26
48. Hospital Definition in states where Clinical Establishment Act is not applicable.......26
49. Registration of Hospital under Shops and Establishment Act in Gujarat
or states where Clinical Establishment Act 2010 is not in force.........................................28
50. As per notification passed by Central Council of Indian Medicine.....................................28
51. Ayurvedic treatment...............................................................................................................................29
52. Physiotherapist Registration Status.................................................................................................29
53. What should be the criteria for Physiotherapist fees in absence of regulated tariff?........29
54. Physiotherapy during post hospitalization period....................................................................29

Ophthalmic Procedures____________________________________________________30-32
55. Multifocal lens...........................................................................................................................................30
56. Pre & Post Hospitalization Benefit for cataract..........................................................................30
57. Optho- Laser assisted cataract surgery..........................................................................................30
58. Femto Laser Cataract Surgery............................................................................................................30
59. Admissibility of procedure YAG laser in ophthalmology........................................................30
60. Lasik surgery..............................................................................................................................................31
61. Intraocular contact lens........................................................................................................................31
62. Strabismus surgery.................................................................................................................................31
63. Keratoconus- whether cataract capping is applicable?...........................................................31
64. C3R with INTACHS for Keratoconus................................................................................................31
65. Macular Edema and conditions associated with it ...................................................................32
66. Is Inj Avastin payable in Diabetic Retinopathy under day-care?.........................................32
67. Diabetic macular edema etc................................................................................................................32
68. Ozurdex Implant (intravitreal implant).........................................................................................32

Interpretation of policy terms and conditions_________________________33-45

69. The limit for surgeries on bilateral organs...................................................................................33
70. Continuation of policy in migration.................................................................................................33
71. Renewal of policy.....................................................................................................................................33
72. Revised enhanced Sum Insured.........................................................................................................33
73. Cataract limit after migration.............................................................................................................34
74. Tests done abroad....................................................................................................................................34
75. What is the Grace period for renewal of policy?.........................................................................34

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76. Domiciliary Hospitalization.................................................................................................................34

77. Cataract sublimit......................................................................................................................................35
78. Application of Limits..............................................................................................................................35
79. Janata / Senior Citizen Policy Procedure Capping:....................................................................35
80. Zone Capping:............................................................................................................................................35
81. Fraud Detection best practises...........................................................................................................35
82. Application of close proximity...........................................................................................................35
83. Enhanced Sum Insured Room Rent eligibility.............................................................................36
84. Premium calculated on running age or completed age?.........................................................36
85. How to deal with cases having No intimation or delayed intimation
and delayed submission?......................................................................................................................36
86. Related Medical Practitioner...............................................................................................................37
87. Do we pay Consultation/Visit charges of doctors......................................................................37
88. If Patient is admitted in a hospital owned by their relative...................................................37
89. Contribution clause application........................................................................................................37
90. Can the room rent eligibility be clubbed from policies of different Insurers?..............40
91. Clubbing of two policies........................................................................................................................40
92. Insured has 2 or more policies from New India. There is a claim for
cataract/maternity which exceeds the capping..........................................................................40
93. Maternity Benefit: Both husband and wife separately covered
under our GMC Policy.............................................................................................................................40
94. Claim during two policy periods:......................................................................................................40
95. Application of Co-pay:............................................................................................................................41
96. Co-pay on sublimit...................................................................................................................................41
97. Should we apply co-pay on PPN limit since it is already a negotiated rate?..................41
98. Cochlear Implant coverage..................................................................................................................41
99. Sleep Apnea................................................................................................................................................42
100. Obesity & obstructive sleep apnoea.................................................................................................42
101. Obesity treatment not payable—complication word applies
to obesity or obesity treatment.........................................................................................................42
102. Bariatric surgery carried out in a lower than normal BMI individual
for uncontrolled DM….is this payable?...........................................................................................42
103. Heat/Cold Strokes/ accidental poisoning - are these accidents?........................................42
104. Psychiatric conditions in the presence of the disease like
Vitamin deficiency….is this payable?...............................................................................................42
105. We are denying dentigerous cysts on the grounds that dental
treatment is not payable.......................................................................................................................42
106. Dental Implants........................................................................................................................................43
107. Hospital definition for dental treatment........................................................................................43
108. Gynaecomastia..........................................................................................................................................43
109. Acute Tonsillitis........................................................................................................................................43
110. Skin disorder..............................................................................................................................................44
111. Hyperbaric Oxygen therapy.................................................................................................................44

Group policies_______________________________________________________________46-47
112. Organizational/ Corporate Buffer Floater.....................................................................................46
113. Group policy issues.................................................................................................................................46

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114. New born Baby coverage......................................................................................................................46

115. Pre natal and post natal.........................................................................................................................46
116. Maternity Claim in Tailor Made Policy:..........................................................................................47
117. What about the variants in maternity?...........................................................................................47

Maternity complications and Infertility_________________________________48-51

118. Endometriosis in scar – post LSCS....................................................................................................48
119. Endometriosis waiting period............................................................................................................48
120. Hysterectomy for conditions not mentioned in 2 yr waiting period,
for example Adenomyosis....................................................................................................................48
121. Uterine Septum.........................................................................................................................................49
122. Hysterectomy followed by delivery in placenta previa...........................................................49
123. Complication secondary to LSCS surgery......................................................................................50
124. Can we consider other life threatening conditions like
Rectus sheath hematoma during pregnancy................................................................................50
125. Hysteroscopy with biopsy....................................................................................................................50
126. Ectopic pregnancy...................................................................................................................................50
127. For ectopic pregnancy the limit available is Maternity limit or
available sum insured?..........................................................................................................................50
128. Incisional Hernia arising out of LSCS..............................................................................................50
129. Infertility -Fibroid uterus, ovarian cyst; evaluation or/and
treatment for non-admissible diseases like infertility.............................................................51
130. Thermal balloon ablation.....................................................................................................................51
131. Embolisation of uterine artery...........................................................................................................51

Accidental Injury /Self harm______________________________________________52-54

132. Religious fasting, Toxicity/ poisoning due to self-medication..............................................52
133. In case of consumption of Dettol/ benzodiazepam/ phenyl or burn
cases where no MLC is done by the hospital................................................................................52
134. Accidental injuries in the first 30 days after inception of policy.........................................53
135. Accidental bodily injury to minor for driving two / four wheeler......................................53
136. Injury as a result of active participation in any hazardous sports......................................53
137. Use of Tobacco leading to cancer......................................................................................................53
138. Pancreatitis or cirrhosis of liver with past history of alcohol...............................................53

Congenital Disorders_______________________________________________________55-57
139. Development Dysplasia of HIP...........................................................................................................55
140. Indirect Inguinal Hernia........................................................................................................................55
141. Inguinal Hernia in a child aged 3 yrs...............................................................................................55
142. Congenital Cataract.................................................................................................................................55
143. Spina Bifida.................................................................................................................................................55
144. Undescended Testis/Congenital External.....................................................................................55
145. ArterioVenous malformations............................................................................................................56
146. List of Inherited and Acquired Genetic Disorders.....................................................................56

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147. Admissibility of stem cell treatment claims:................................................................................57

148. Donor Expenses:.......................................................................................................................................57

Claim Adjudication_________________________________________________________58-63
149. Reasonable charges for Diagnostics................................................................................................58
150. Proportionate deduction of Implants..............................................................................................58
151. Accidental fall............................................................................................................................................58
152. Artificial Limbs..........................................................................................................................................58
153. Decision for reasonable and customary deduction...................................................................58
154. LOS (length of stay) to be specified..................................................................................................59
155. Proportionate deduction in Breach Candy....................................................................................59
156. Case of eligibility of the room category..........................................................................................59
157. Verification of proposal form in case of pre-existing illness.................................................59
158. Clarity of Diabetes and Hypertension related disorders........................................................61
159. If migrated from 2007 to 2012 and loading paid for 2 years,
then will 50% and 75% be payable?................................................................................................61
160. Waiting period for Diabetes and Hypertension..........................................................................62
161. How to define reasonable and customary?...................................................................................62
162. Hepatitis B and Hepatitis C infection and related Complications.......................................63
163. Ebola infections are payable or not..................................................................................................63
164. Tumour is present before HIV infections......................................................................................63
165. Some STDs which may have other routes of transmission like
blood transfusion payable or not?....................................................................................................63
166. Plastic Surgery in cases of accidents...............................................................................................63

Administration of medications in day care_____________________________64-65

167. Anti Rabies Vaccination.........................................................................................................................64
168. Oral chemotherapy..................................................................................................................................64
169. Inj Rituximab.............................................................................................................................................64
170. Infliximab/Remicade, Enbrel/ Etanercept therapy..................................................................64
171. Inj Botox.......................................................................................................................................................65
172. Intra articular injections.......................................................................................................................65
173. Zolandronic acid (aclasta) therapy...................................................................................................65
174. Herceptin: (Traszutumab)...................................................................................................................65
175. Injection Falsodex....................................................................................................................................65

Suggested Daycare Procedures_______________________________________________66

176. Treatments usually done on OPD or Day care basis and being converted to IPD........66
177. Arthroscopy................................................................................................................................................66
178. Implant/DJ stent removal post 60 days.........................................................................................66
179. Hospitalisation for Epidural block....................................................................................................66
180. Reduction and Strapping for Clavicle Fracture...........................................................................66

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Diagnostic Procedures_____________________________________________________67-68
181. How to deal with CT guided Angiography.....................................................................................67
182. MRI.................................................................................................................................................................67
183. Admission for PET SCAN?....................................................................................................................67
184. Can we settle a claim in case there is positive diagnosis but there
is no active treatment?...........................................................................................................................67
185. Diagnostic procedures done to evaluate the condition of patient......................................68

Process Related Queries_______________________________________________________69

186. Clarification on repudiated file..........................................................................................................69
187. CB confirmation from DO.....................................................................................................................69
188. Delay condonation confirmation.......................................................................................................69
189. What are the issues which are encountered with regard to 64 VB?..................................69

Documents Deficiency_____________________________________________________70-72
190. Separate bill for professional fees.....................................................................................................70
191. Pharmacy receipts (FDA), retail and In-house pharmacy.......................................................70
192. Batch number and expiry dates are not available......................................................................70
193. In-house pharmacy.................................................................................................................................70
194. Verifying documents from non-network hospitals...................................................................70
195. Few auditors are insisting of X ray and CT scan plates in each case..................................71
196. Stickers and invoices of Implants......................................................................................................71
197. Claims received from rural areas:.....................................................................................................71
198. In Government hospitals photocopy of discharge summary and reports
are provided to patients........................................................................................................................71
199. No name of the patient mentioned on the Indoor Case sheets............................................72
200. Payment of Doctor’s fees by Demand Draft..................................................................................72
201. Admission seems for mainly investigation purpose.................................................................72
202. Cases of negligence on the part of treating Doctor....................................................................72

Day-care Procedure related queries_____________________________________73-74

203. Day care surgeries in non PPN Hospitals......................................................................................73
204. Death case hospitalization less than 24 hours, Chest pain
– hospitalization less than 24 hours................................................................................................73
205. Decision of Day care procedure.........................................................................................................73
206. Fracture on OPD basis............................................................................................................................73
207. In cases where CAG is normal.............................................................................................................73
208. Should one day of stay be payable for any day care procedure?.........................................73
209. If the procedure is not mentioned in the list, even of Mediclaim 2012,
then does it still remain a Day Care procedure?.........................................................................74

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Deductions in claim____________________________________________________________75
210. Discuss list of surgeries where assistant surgeon is required..............................................75
211. How to decide when IC and TPA do not agree about requirement
for assistant surgeon?............................................................................................................................75
212. If there is fever, fall, stone associated with Maternity..............................................................75
213. Pre and post hospitalization benefit................................................................................................75
214. Surgical Cases: Cotton, Betadine, Gauzes, Syringes,
needles ….are these payable?..............................................................................................................75

PPN issues____________________________________________________________________76-78
215. If bill break-up is provided in GIPSA cases, whether NMEs should be deducted?.......76
216. Whether there is any sublimit or capping in GIPSA packages?............................................76
217. PPN Hospital Discount...........................................................................................................................76
218. In Cashless hospitalisation many grievances are received for GIPSA packages...........76
219. In case of partial PPN procedure/ more than one surgery in
single admission / complicated cases.............................................................................................76
220. Co-morbidity or complex cases in PPN..........................................................................................77
221. PPN Hospital not providing breakup of medicines...................................................................77
222. Cataract Surgery PPN sublimit...........................................................................................................77
223. When hospitals come for open billing for the PPN tariff........................................................77
224. Eligible PPN room categories.............................................................................................................77
225. In reimbursement claims, PPN hospital is charging more than GIPSA PPN rates.......78

Annexure I- Assistance Surgeon_____________________________________79-87

Annexure II- Congenital Internal____________________________________88-91

Annexure III- Congenital External___________________________________92-94

Annexure IV-Genetic Disorders____________________________________ 95-121

Annexure V-IRDA Claim Form____________________________________ 122-125

Annexure VI-Claim Adjudication Sheet_______________________________ 126

Annexure VII-Repudiation Statement________________________________ 127

Annexure VII-Repudiation Statement________________________________ 128

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Medical Advancements
1. Peritoneal Ambulatory dialysis taken at home?
Resolution: Not payable. A claim is admissible only if there is 24 hour hospitalisation/
included in day-care procedures. Any treatment such as Peritoneal Ambulatory dialysis
taken at home is not payable. It is also not the ideal procedure for dialysis. (Also refer
Exclusion clause 4.4.15 of Mediclaim Policy-2007, which excludes cost of instruments used
for ambulatory peritoneal dialysis.

2. Cyber knife:
Cyber knife is another high-tech recognized surgery with very high cost. The centers which have
those facilities are marketing this procedure for many ailments which can be commonly done
by the routine surgical procedure. Advantage of cyber knife is debatable in these procedures.
Please clarify the admissibility of this procedure?
Resolution: Basic principle shall remain to pay under ‘reasonable and customary’ clause.
Cyber knife is permissible as day care surgery for the treatment of cancer and malignant
tumor. (Circular ref. HO/HEALTH/CIR NO.07/2009/IBD/admn:18 dated 24th February,
2012: Cyberknife surgery for treatment of cancer)

3. Stereotactic radio surgery

It is used in brain surgery for both malignant and benign lesions which require high precision
for the benefit or better outcome of the case. We can take underwriters approval in case to case
basis. Aetna considers stereotactic radiosurgery medically necessary according to the following
selection criteria:
1. Cranial stereotactic radiosurgery with a Cyberknife, gamma knife, or linear accelerator
(LINAC) is considered medically necessary when used for any of the following indications:
a. Symptomatic, small (less than 3 cm) arterio-venous (AV) malformations,
aneurysms, and benign tumors (such as acoustic neuromas (vestibular
schwannomas), craniopharyngiomas, hemangiomas, meningiomas, pituitary
adenomas, and neoplasms of the pineal gland) if the lesion is unresectable due to
its deep intracranial location or if the member is unable to tolerate conventional
operative intervention; or
b. For members with trigeminal neuralgia that has not responded to other more
conservative treatments
c. For treatment of brain malignancies (primary tumors and/or metastatic lesions).
2. Stereotactic body radiation therapy with a Cyberknife, gamma knife, or LINAC is
considered medically necessary for localized malignant conditions within the body
where highly precise application of high-dose radiotherapy is required (e.g., lung
or liver metastases not amenable to surgery, medically inoperable early stage lung
cancer, primary liver cancer not amenable to surgery, spinal and para-spinous tumors,
not an all inclusive list).
3. Fractionated stereotactic radiotherapy is considered medically necessary when criteria
for stereotactic radiosurgery are met. Fractionated stereotactic radiotherapy is useful
for treatment of tumors in hard-to-reach locations, tumors with very unusual shapes,

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or for tumors located in such close proximity to a vital structure (e.g., optic nerve or
hypothalamus) that even a very accurate high-dose single fraction of stereotactic
radiosurgery could not be tolerated.
4. Stereotactic proton beam radiosurgery:
Chordomas or chondrosarcomas arising at the base of the skull or cervical spine
without distant metastases; or
Malignancies in children (21 years of age and younger); or
Uveal melanomas confined to the globe
Need to restrict upto the cost of conventional surgeries.
Resolution: Agree with the given suggestion. For Stereotactic radiosurgery as defined in the
above conditions, the entire cost is payable.

4. Trigeminal neuralgia-gamma knife/cyber knife

Can we pay gamma knife/cyber knife surgeries for trigeminal neuralgia as the area is not
accessible to open surgery otherwise? Trigeminal neuralgia can be debilitating most of the
times and the inclusion of this surgery for such conditions can be very beneficial medically –
also since the rates are not fixed we can cap such procedures up to a limit of Rs 50000. Should
be allowed only in refractory cases.
Resolution: This is not payable. Exception can be made in some cases where there is evidence
of no response to /refractory trigeminal neuralgia, as per the guidelines given below:
Following are the indications for admissibility of cyber knife in Trigeminal Neuralgia:
1. Failure to control the symptoms with Multiple antiepileptic medication( two
or more medicines listed in the foot note are used for at least 3 months)
(Look for the number of medicines used and their duration along with the documentary
proof for recurrence in spite of medication)
2. ConditWions where Antiepileptic medications are contra indicated.
a. Drug reaction with anti-epileptic Medications.
b. Anticonvulsant medications pose risks of sedation and ataxia, particularly in
elderly patients, which may make driving or operating machinery hazardous.
c. They also may pose risks to the liver and the hematologic system.
(Look for the Documentary evidence for established drug reaction/ adverse effect as
described above.)
3. Patients who develop trigeminal neuralgia when younger than 60 years with
the failure of medical management.
FOOT NOTE: Common Medicines used for Trigeminal Neuralgia:
Anti-Epileptic Drugs:
a. Carbamazepine and oxcarbazepine are considered first-line therapy
b. Gabapentin has demonstrated effectiveness in trigeminal neuralgia (TN),
especially in patients with multiple sclerosis (MS).
c. Lamotrigine Therapy
d. Phenytoin Therapy

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Non Antiepileptic Drugs:

a. Baclofen therapy
b. Dextromethorphan
c. Botulinum toxin

5. Robotic surgeries
Used in wide varieties of surgeries of Carcinoma, hysterectomy, etc. In fact the laparoscopic surgeries
are slowly being replaced by Robotic surgeries. The Insurer reserves the right to pay fully for cancers
of prostrate/brain surgeries as an exception. But these days an increasing number of cases require
high precision mostly in brain surgery. Since the premium fixed does not take into account these
costly procedures, it is better to consider the conventional surgery or the lap procedures that are
customarily done under reasonable, necessary and customary care. The patient is self-insurer for the
difference. Is it not possible to pay for the complete operation and deduct only the cost of the Robotic
Arm? This is usually about 75K – 2.5 Lakhs depending on the time and complexity of the surgery?
Resolution: Payable up to reasonable and customary limit (laparoscopic surgery for the
same ailment). Exceptions for full payment of claims made only for cancers of prostrate or
brain surgeries.

6. Pacemaker battery replacement

Resolution: Pacemaker battery replacement may be paid as a day care procedure as per the
following conditions:
1.    If the claim for surgery for initial implantation of pacemaker device was paid under
our policy, then subsequent surgery for pacemaker battery replacement is payable,
subject to continuous coverage under our policy.
2.    If the surgery for initial implantation of pacemaker device was not paid under our
policy because of no cover or pre-existing disease, then the replacement of pacemaker
battery will be payable only after completion of 48 months of continuous coverage
under our policy.

7. Enhanced External Counterpulsation (EECP)

The procedure is done for the Ischaemic heart diseases. EECP is been widely practiced by
cardiologist as alternative treatment or non-invasive procedure for persistent angina symptoms
– can we consider it in proven treatments? It’s an OPD procedure which can be done in sessions
in IPC centres which do not comply with hospital definition. Often given at stand alone, non-
hospital centres. Legal forums have ruled in favour of EECP - the same is used widely in US and
European nations - but the same in India will be used by Ayurvedic practitioners. Asian Heart in
Mumbai practises EECP.
Resolution: A claim is admissible for treatment requiring hospitalisation for a minimum of
24 hours. Any treatment taken in OPD or for less than 24 hours is not admissible. An exception
is made for the 24 hour time limit only for specific procedures included in the list of day-care
procedures in our policies.
EECP is an OPD procedure. It does not require hospitalisation. It is not included in the list of
day-care procedures. EECP is an exclusion as per the policy clause 4.4.22 in Mediclaim 2012
policy. Hence it is not payable.

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8. Bio- absorbable stents

Accepted by CSI, used by Cardiologists in India and in European Society. We got reply that this
is not customary and hence need not be admitted. It is presumed in terms of number of stents
used at present, these absorbable stents are very limited in use and hence not customary and
therefore not admissible. Does this mean that we can pay customary charges? For example,
biodegradable stents are for Rs. 2.5 lakhs. Normal stent is for Rs. 1.00 lakh. Can we pay 1 lakh?
Resolution: Agree with the suggestion given by TPAs to pay up to Drug Eluting Stent (DES) cost.

9. ‘Plasmapheresis’
Especially indicated for treatment of Neuromyelitis Optica.
Plasmapheresis is a process in which the liquid in the blood, or plasma, is separated from the
cells. In sick people, plasma can contain antibodies that attack the immune system. A machine
removes the affected plasma and replaces it with good plasma. The process is similar to kidney
dialysis. Plasma exchange is also a similar process where affected plasma is replaced with the
donor plasma or plasma substitute. This procedure is a day-care procedure like Dialysis.
The Apheresis Applications Committee of the American Society for Apheresis periodically
evaluates potential indications for apheresis (Plasmaparesis)
The following are some of the indications, and their categorization, from the society’s 2010 guidelines
Category I: Disorders for which apheresis is accepted as first-line therapy, either as a primary
standalone treatment or in conjunction with other modes of treatment are as follows:
1. Guillain-Barre syndrome
2. Myasthenia gravis
3. Chronic inflammatory demyelinating polyneuropathy
4. Hyperviscosity in monoclonal gammopathies
5. Thrombotic thrombocytopenic purpura
6. Goodpasture syndrome (unless dialysis dependent and no diffuse alveolar
hemorrhage)
7. Hemolytic uremic syndrome (atypical, due to autoantibody to factor H)

Category II: Disorders for which apheresis is accepted as second-line therapy, either as a
standalone treatment or in conjunction with other modes of treatment are as follows:
1. Lambert-Eaton myasthenic syndrome
2. Multiple sclerosis (acute central nervous system demyelination disease unresponsive
to steroids)
3. Red cell alloimmunization in pregnancy
4. Mushroom poisoning
5. Acute disseminated encephalomyelitis
6. Hemolytic uremic syndrome (atypical, due to complement factor mutations)
7. Autoimmune hemolytic anemia (life-threatening cold agglutinin disease)
8. Systemic lupus erythematosus (severe)
9. Myeloma cast nephropathy
10. Cryoglobulinemia
11. Anti-GBM disease

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Resolution: Plamapheresis is payable in day care procedures for the above mentioned
ailments whenever they are admissible as per the policy terms and conditions.

10. Dotatate Therapy for Neuro-Endocrine Tumours

Dotatate therapy cannot be admitted, though it involves hospitalisation, as it is still
experimental.
Resolution: Not Payable since it is Experimental.

11. HIFU (High intensity focused ultrasound)/MR GUIDED Focused

Ultrasonographic Surgery(MRgFUS)
HIFU may be used for Fibroid uterus (Myoma). Conventionally, the treatment for fibroid is
Myomectomy or hysterectomy which requires hospitalization, and however, due to the advancement
of technologies, such hospitalization is not required. Since we have specific waiting period for
Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus, and the treatment for
these should be payable irrespective of the modality after the waiting period is over. HIFU/MRgFUS
is especially indicated in the patients who are of younger age, unmarried etc.
Resolution: Payable as day care up to the reasonable cost of hysterectomy if not related with
infertility. It can be considered only in a hospital which meets the hospital definition, not
payable if carried out in Radiology Diagnostic centres.

12. Artificial Pancreas system

The FDA is helping in development of an artificial pancreas device system (APDS)—an innovative
device that automatically monitors blood glucose and provides appropriate insulin doses in
people with diabetes who use insulin. Indication - Advised in diabetic persons.
Resolution: Not payable since external devices or durable medical equipment are not
payable, which would include APDS.

13. Coblation Assisted Tonsillectomy
Unlike traditional tonsillectomy procedures, which remove tonsils by cutting and/or burning,
Coblation is advanced technology that combines gentle radiofrequency energy with natural
saline - to quickly, and safely remove tonsils. Coblation tonsillectomy significantly reduces the
operation time, intraoperative blood loss and postoperative pain, and was associated with early
recovery of dietary routine.
Resolution: Payable as per PPN package or reasonable and customary charges.

14. Laser Tonsillectomy
Resolution: Payable as per PPN package or reasonable and customary charges.

15. Deep Brain Stimulation

Deep brain stimulation (DBS) is a surgical procedure used to treat several disabling neurological
symptoms—most commonly the debilitating motor symptoms of Parkinson’s disease (PD), such
as tremor, rigidity, stiffness, slowed movement, and walking problems. Can be considered after
waiting period of 4 years.

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DBS uses a surgically implanted, battery-operated medical device called an implantable pulse
generator (IPG)—similar to a heart pacemaker and approximately the size of a stopwatch—to
deliver electrical stimulation to specific areas in the brain that control movement, thus blocking
the abnormal nerve signals that cause PD symptoms.
The Federal Food and Drug Administration (FDA) approved deep brain stimulation of the
thalamus for the treatment of tremor in 1997. Subthalamic DBS for Parkinson’s disease was
FDA approved in 2002, and globuspallidus DBS was FDA approved in 2003. Treatment taken for
Parkinson’s resistant to medical line of management, Treatment of tremors, Globus pallidum.
Percentage of those who suffer from this disorder is not high. There are proved good results of
the surgery and it is followed by all the doctors
Resolution: Can be considered payable only if it forms a part of discharge advice only
for diagnosed cases of Parkinsonism after a 4 year continuous coverage. Not payable for
Psychiatric ailments. Not to be considered on standalone basis or when hospitalisation is
done only for administration of this therapy.

16. LASER Assisted Hemorrhoidectomy

It is a minimally invasive surgical hemorrhoidectomy procedure, a precision laser is used to cut
away hemorrhoid tissue and seal the blood vessels that lead to the hemorrhoid. The laser that
is usually used here is a neodymium-Yttrium-aluminum-garnet laser or carbon dioxide or argon
lasers. “Benefits are less bleeding, less pain, high precision, less complications; however, cost,
availability and expertise are the drawbacks.
In the network hospitals we should restrict the package to the treatment of the disease, therefore,
treatment of the same by way of any modality the package should be capped like that. Presently
the PPN hospitals are using the different modalities and doing the open billing on the pretext of
that they do not have any package for said modality.
Resolution: Payable as per PPN package of conventional procedure or reasonable and
customary charges.

17. LASER Assisted Prostatectomy
LASER Assisted Prostatectomy is one of the alternatives to transurethral resection of the
prostate (TURP). The lasers used are diode laser, holmium laser, ThulliumLaser or green laser
(KTP). Other alternatives to TURP are Visual Laser Ablation of Prostate (VLAP), Interstitial
Laser Coagulation (ILC) and Holium Laser Resection of Prostate (HoLRP)
Advantages over open prostatectomy, include smaller incisions, less pain, less bleeding, less risk
of infection, faster healing time, and shorter hospital stay. The cost of this procedure is higher
than TURP.
Resolution: Payable as per PPN package or reasonable and customary charges.

18. LASER Assisted End Arterectomy

Laser Assisted End Arterectomy is a procedure to clean out an artery and restore normal blood
flow through the artery. It removes diseased material from the inside of an artery, and also
removes any occluding atheromatous deposits, the aim being to leave a smooth lining within
the vessel, so the blood can flow normally. It is currently commonly done for carotid arteries or
lower limb arteries.

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Conventional methods, via balloons or excision and grafting, would have demonstrably inferior
results.Although laser endarterectomy has recently been suggested as useful in the treatment of
arteriosclerotic obstructions, the “”in vivo”” clotting effects have not been well delineated. These
findings suggest that laser endothelial evaporation leads to increased thrombotic potential in
the early post-operative period in comparison to surgical endarterectomy.
Resolution: Payable as per reasonable and customary charges of surgical end arterectomy.

19. Retrograde Intra renal Surgery (RIRS)

Retrograde intrarenal surgery (RIRS) is a procedure for doing surgery within the kidney using
a fiberoptic endoscope.In RIRS the scope is placed through the urethra (the urinary opening)
into the bladder and then through the ureter into the urine-collecting part of the kidney. The
scope thus is moved retrograde (up the urinary tract system) to a position within the kidney
(intrarenal). RIRS may be done to remove a stone The advantages of RIRS over open surgery
include a quicker solution of the problem, the elimination of prolonged pain after surgery, and
much faster recovery.
RIRS is indicated in Treatment stones, malignancies and removal of foreign body in upper
tract,Branched staghorn calculus,Multiple stones in separate locations within the collecting
system etc.Stones form the most common indication for RIRS yet, the technique has been
extended for treatment of pelvi-ureteric junction obstruction and upper tract transitional cell
carcinoma (TCC) management
Resolution: Payable as per PPN package or reasonable and customary charges.

20. VAFT (Video Assisted fistula Treatment)

It is a minimally invasive anal sphincter saving technique for treating complex anal fistulas. Using
direct end luminal vision, it also helps to visualize secondary tracts or chronic abscesses. However,
the challenge is the cost, restricting to the conventional treatment is the option as It is a method of
performing the procedure and not a separate service, although technically advanced.
Resolution: Payable as per PPN package or reasonable and customary charges.

21. Balloon Kyphoplasty

A minimally invasive procedure that uses a balloon to lift the vertebrae and create a cavity for bone
cement to stabilize the fracture.As per the new and revised definition, these are otherwise payable,
only if we explain and incorporate customary  in the definitions then we can restrict up to the
conventional treatments. However, in future, these treatments will become customary, hence, stamp
in the policy or capping(either in policy or negotiation under PPN packages) is necessary.
Resolution: Payable as per PPN package or reasonable and customary charges asper the
standard surgical treatment of the spinal fracture.

22. Balloon Sinuplasty

Balloon Sinuplasty (BSP) is a safe and effective sinus procedure for chronic sinusitis patients
seeking relief from uncomfortable sinus pain symptoms. But it may not be appropriate for all
chronic and recurrent sinusitis patients.
Resolution: Payable as per PPN package for septoplasty or reasonable and customary
charges.

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23. Single Incision Laparoscopic Surgery for abdominal surgeries

In the network hospitals we should restrict the package to the treatment of the disease, therefore,
treatment of the same by way of any modality the package should be capped like that. Presently
the PPN hospitals are using the different modalities and doing the open billing on the pretext of
that they do not have any package for said modality.
Resolution: Payable as per PPN package/reasonable and customary charges for the
conventional procedure.

24. Cardiology – CABG with MICS
MICS CABG is a beating heart, multi-vessel CABG procedure in which the anastomoses
are performed under directvision through an anterolateral mini-thoracotomy. Complete
revascularization can be achieved through a small thoracotomy. It can be considered as
Technological advancement. Since the technology is fairly new and costly the capping can be
introduced for the same.
Minimally Invasive Heart Surgery has advantages like less blood loss, reduced post-operative
discomfort, faster healing times and lowered risk of infections, as well as eliminating the
possibility for deep sternal wound infection or sternal non-union. This procedure makes heart
surgery possible for patients who were previously considered too high risk for traditional surgery
due to age or medical history. Patients referred for this procedure may have Coronary Artery
Disease (CAD); aortic, mitral or tricuspid valve diseases; or previous unsuccessful stenting.
Resolution: Payable as per PPN package for CABG or reasonable and customary charges.

25. DENVAX is dendritic cell-based cancer immunotherapy

The DENVAX is dendritic cell-based cancer immunotherapy for solid cancers in various stages
of the disease. It is autologous treatment, which involves patient’s own mononuclear cells
transformed into cancer-specific dendritic cells.
Dendritic cell therapy comes under the heading of Biological Therapy of Cancer, the fourth
modality of cancer treatment after surgery, radiation and chemotherapy.
DENVAX shows most promise at preventing a recurrence of cancer after surgery, chemotherapy
or radiation because the immune system will need to recognize and attack a smaller number of
cancer cells. Since the technology is fairly new and expensive the capping can be introduced for
the same.
Resolution: Not a day-care procedure. Payable if part of chemotherapy/ radiotherapy/
or related hospitalisation. Payable in Pre/post hospitalisation expenses of an
admissible claim.

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Charges in Hospital Bill

26. Modified final hospital bill incorporating Surgeon/Anaesthetist /

Visit Charges
This refers to the wordings under 2 and 3 of Note under 2.6 of Mediclaim Policy 2007-
The wordings of 2nd point are: “No payment shall be made other than as part of the
hospitalization bill.”
The wordings of 3rd point are: “However, the bills raised by Surgeon, Anaesthetist directly and
not included in the hospitalization bill may be reimbursed in the following manner:
a. The reasonable, customary and necessary Surgeon fee and Anaesthetist fee would be
reimbursed, limited to the maximum of 25% of Sum Insured. The payment shall be
reimbursed provided the insured pays such fee(s) through cheque and the Surgeon
/ Anaesthetist provides a numbered bill. Bills given on letter-head of the Surgeon,
Anaesthetist would not be entertained.
b. Fees paid in cash will be reimbursed up to a limit of Rs.10,000/- only, provided the
Surgeon/Anaesthetist provides a numbered bill.”
We settled claims within above limits, and then member comes again with main bill which
includes the above Charges. How to go about it? Can we pay total amount or limit the payment
to the bills submitted earlier.
Resolution: Hence before paying separate bills collect main hospital bill.

27. Separate bills given by Anaesthetist and Surgeon exceeding the Rs

10,000/- cash payment limit.
If separate bill is charged for the surgeon and anesthetist paid in cash --- We pay Rs10000/- Eg.
Surgeon charged Rs 10000, Anesthetist Rs 5000. Are we are supposed to pay Rs. 15000/-?
Resolution: Yes. Each payment cannot exceed Rs 10000 for cash, and 25% of sum insured or
Rs 20,000 as per applicable policy, for cheque payments.

28. Proportionate deductions on Surgeon and Anaesthetist bills

As per Note-3 (A & B) under clause 2.0 Surgeon/Anaesthetist fees can be paid maximum up
to Rs 10,000/- if the payment is made by cash, and maximum 25% of S.I. or Rs 20000/- as per
applicable policy, if paid by cheque provided the Surgeon/Anaesthetist provides a numbered
bill. Require confirmation whether proportionate deduction as per the entitled room category is
applicable on doctor fees limited to Rs 10,000/-(paid by cash) and 25% of S.I. (paid by cheque).
Resolution: Yes. The deduction should be made on both cash payment and cheque payment.

29. Diet Charges

Diet charges currently not payable may be paid specifically for diabetic diet, post-operative,
CKD cases
a. Agreed
b. Not agreed
Resolution: As per FICCI list, charges for patient diet provided by hospital are payable. Diet
charges for attendant or food charges are not payable.

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30. Laparoscopic / Endoscopic surgeries: disposable items

Recent advancements and the emphasis on prevention of blood borne diseases have resulted in
excess of utilization of disposable items for surgery (Good practice for the patient safety) but
they cost more for insurer. Most of such listed items belong to “Non Admissible list”.
Resolution: Basic principle shall remain to pay under ‘reasonable and customary’ clause.
Refer FICCI list for non-admissible items.

31. Charges for consumables

such as cautery cord, camera cover, laser fiber, harmonic scalpel, Harmonic ultra-scissors
(cost for these may be upto 30K), Bulk drugs like Anaesthetic Servoflurane 250 ml for a single
patient (GA is given), Handrub lotions, etc. What constitutes a ‘surgical appliance’ that is
clearly ‘reimbursable’, and what is to be denied? Are these actually single use consumables
to be reimbursed as such? How is art usage of bulk issued drugs (like the examples given)
to be handled?
Resolution: For very expensive items a percentage of the cost (25%) may be paid, the
limitation being covered by ‘reasonable and customary’ costs.
a) If it is a durable item, which shall later on continue to be used in domiciliary situation
– Not payable.
b) Bulk issue of items: Not payable.. Servoflurane: 20% of the cost, subject to GA being
used and if no ‘anaesthesia charges’ are billed.
c) To specify certain named items: Cautery cord, camera cover, C-arm cover are not
payable.: Their cost is charged under O.T. charges
d) Those items which are deemed non-payable on FICCI notation/recommendation
shall not be paid except as already directed.
e) Equipment Fee: Payable against rental receipt, or if charged in hospital bill (as
often happens when operating surgeon carries own specialized instrument like
laproscope) then as in example below:
Say Hospital A charges’ x’ amount for a surgery which requires specialized equipment. Then
for Hospital B, which is a comparable institution except that it does not have that specialized
instrument, if their total cost for that surgery, including this equipment charge, is less than
or equal to ‘x’ – Payable. If it exceeds that charge, amount up to such charge may be paid,
preferably after negotiation/rate revision.

32. Skin stapler payment

Resolution: Staples/Stapler gun whether reusable or disposable if used for skin stapling,
it is an alternative to conventional suturing methods. They can be paid up to 25% of the
cost under reasonable and customary, since the cost of suture material which is payable is
approximately 25% of the cost of skin staplers at present.
For example, the usual cost of skin staplers varies from Rs 800 to 1200, while the cost of
vicryl suture material costs approximately Rs 380-600 at present.

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33. Stapler for stapler hemorrhoidectomy should be payable

Stapler/stapler guns have been allowed in the PPN packages for Stapled Hemorrhoidectomy,
for the treatment of haemorrhoids without any deductions or short payment of 25% etc. The
entire cost of staplers was allowed in the Stapled Hemorrhoidectomy PPN package because it
is a requirement of the procedure. For procedures such as Hernia repair like Incisional hernia,
Umbilical hernia, ventral hernia, inguinal hernia etc, it is a replacement of sutures.
Therefore, in our opinion, even in reimbursement cases whether from cities where PPN
is applicable or NON PPN places, we should allow full reimbursement of staplers.
Resolution: Agreed. If staples/staplers used for internal surgeries, 100% of the amount will
be payable.

34. Hood- part of operation gown

Hood is required because at a time of operation the patient blood flashes on the face of surgeon.
This is a personal protective equipment required for the surgeon’s or assistant’s safety. Cost
should be borne by service provider, not the patient. These types of billing patterns can be seen
in the secondary set up where the OT charges are 40-50% as compared to the tertiary plus
hospitals where the OT charges are 100% e.g. Medanta/Apollo etc.
Resolution: Not Payable as per FICCI list. It is considered as part of operation gown.

35. Harmonic Ace, Harmonic Shears- are they payable?

As per IRDA, harmonic scalpel is payable under OT Charges, not separately. If OT charges are
very less, then how to deal such cases.
Resolution: Payable as per reasonable and customary use even if charged separately from
OT charges. (Up to 100% of surgeon charges).

36. Surgical Appliances: There is no objective definition of an

Operation Theatre
Ideally equipment like the Endoscopy, laparoscope, Staplers, etc. form part of an advanced OT.
In smaller hospitals, however, these are carried by the visiting surgeon & billed for per use,
separately.
In a Study done in the UK, some of the essentials of an OT have been cited:
• Good Lighting
• Oxygen supply
• Suction machine
• Operation Table
• Post-operative area
• Temperature regulation
• Piped gases in OT
• Anaesthesia Cart & Machine
• Pulse oxymeter
• Electrocautery machine
• Sterilization techniques for OT

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• Autoclaving
• Manual instruments: scalpel, scissors, retractors, Artery forceps, forceps, needles,
syringes, distilled water, etc.
• Scrubbing area
• Emergency tray for tracheostomy
These should be the minimum requirements in an OT in a nursing home
These should not be paid for over and above the OT limit, however anything else may
be billed separately for
Resolution: An Operation Theatre should contain all the above items. Apart from this if any
items are charged we will pay separately. But if the charges as defined in the above list are
charged separately, then we will not pay those charges.
Items that can be paid separately: Eg. C arm, Endoscope and Laparoscope.
The instrument cost and OT charges for a particular procedure is payable provided the total
cost is reasonable (up to 100% of surgeon charges).

37. Monitor charges not mentioned in non-medical list provided

by IRDA.
Monitor is specialised medical equipment used to monitor pulse rate, oxygen saturation and
pulse pattern used in cardiac cases and OT if general anaesthesia is given to patient. These
charges are inbuilt under ICU & OT Charges. Hospitals charge separately as an unbundling
exercise. Need clarification whether this is payable separately in ICU as well as in OT.
Resolution: If Monitor charges are billed separately in ICU/ICCU, they are payable if within
the eligible limit of ICU/ICCU. These charges will attract proportionate deduction if it exceeds
the eligible ICU limit.
Monitor charges are payable in room irrespective of eligibility.

38. Charges for RMO in room, pulse oxymeter or Intensivist charges in

ICU are seen in many hospital bills.
In tertiary care hospitals, usually pulse oxymeter and other charges are a part of ICU/OT and
so the cost is inbuilt into the per hour cost/package cost. In smaller nursing homes this is not
a part of standard OT/ICU. It is not correct to deduct them when billed separately, since each
hospital has a different method of billing. We suggest to add these charges and calculate the
room rent/ICU rent. These charges can be deducted only if room rent charges exceed the eligible
room rent/ICU/ICCU.
Resolution: If Pulse oxymeter or intensivist charges are billed separately in ICU, they are
payable if within the eligible limit of ICU. RMO charges also payable if billed separately but
within the eligible limit of room rent.
These charges will attract proportionate deduction if it exceeds the eligible room rent/
ICU limit.

39. Should we consider HDU charges equivalent to ICU charges

or normal room charges for proportionate deductions.
Resolution: HDU charges to be consider equivalent to ICU charges.

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40. Charges for Trocar/ laser fiber to be considered

in Hernia/ Hemorrhoids/ Holmium laser surgeries? Full/ partial?
Trocar and LASER Fibre are important tools for easy access in minimal invasive surgeries, and
are reusable after sterilization. This item and other similar items need to be tackled since we do
not have a definition of what should a standard OT contain.
Resolution: (a) Full cost of Trocar is payable.
(b) Laser Fibre should be a part of the OT Equipment. It may be paid up to 15% of the total
laser cost since as per FICCI guidelines a laser fibre can be used 10 to 15 times.

41. Pro tack used in hernia payable?

Resolution: Not payable under reasonable and customary.

42. Cross matching charges

It is absolutely necessary and the hospital are charging in any blood transfusion case.In the guide
book it is said that it should be part of cost of blood if the hospital is showing just bifurcation of
cost of blood and cross matching which is reasonable. Can we consider?
Similarly at times hospitals are not charging blood charges at all (blood is donated), so they are
charging cross matching which according to us should be considered but auditors are objecting.
Grouping and cross-matching charges are considered part of the charge for a unit of blood, hence
if this is subsidized or waived, then the mandatory cross-matching charge should be payable.
Resolution: Cross matching charges are payable even if the hospital bills for it separately.

43. Diagnostic charges: Clause no. 2.4 vide Mediclaim Policy 2007
For relevant Laboratory/Diagnostic test, X-Ray under the Mediclaim policy, Usual, Customary &
Reasonable charges can be enforced by
a) Fixing limits for Metro and non- metro cities
b) Proportionate linking to room rent
Resolution: Limits are not fixed as per category of city. Relevant Laboratory/ Diagnostic tests
such as X-rays done during hospitalization are payable proportionately as per the entitled
room category as stated in the policy. But any test performed and billed by an external
diagnostic centre will not be applicable for proportionate deduction.

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Regulation and Legal Issues

44. In case the hospital is owned by an Ayurvedic Doctor

but has visiting Allopathic Doctors…is this eligible as a hospital?
Resolution: Ownership is not the criterion. It should satisfy Hospital definition criterion.

45. Qualified Medical Practitioner is a family member

Clause # 3.6…..QMP shall not include the Insured or his family members….does this necessarily
mean that the treating doctor cannot be a family member?
Resolution: Yes. Since the words “upon the written advice of a medical practitioner” in clause
3.4 have a bearing on the admissibility of the claim, the following procedure is laid down,
where the treating doctor is a family member:
1. No charges for that family member would be admissible
2. If he is the medical practitioner who has recommended hospitalization or a particular
course of treatment, then the claim would have to be examined independent of such
recommendation and seen whether the admission was necessary, or a particular
treatment was necessary. If not, the claim, or the treatment could be denied.

46. RMOs have AYUSH qualifications

Clause 3.6: MEDICAL PRACTITIONER means a person who holds a degree/diploma of a
recognized institution and is registered by Medical Council of respective State of India. The term
Medical Practitioner would include Physician, Specialist and Surgeon and shall not include
INSURED person and members of his family covered under this insurance. This would then
include all doctors who are registered under the MCI irrespective of the field of Practice. Though
Cross Field practice is not allowed as per a Supreme Court Judgment; but on field, the RMOs are
usually QMPs of Allied Medicine
Resolution: Treating doctor is a specialized consultant, who may then employ or make use
of hospital-employed suitable staff to carry out orders, complying with regulations governing
such institutions. It would not be practical to inquire into qualifications of residents, nor
would it serve any useful purpose.

47. Hospital Registration

Definition Clause no. 2.15 vide Mediclaim 2012 Policy. As per Hospitalization definition, it may
be revised as
a. Definition fulfilled if registered with local authorities only
b. If registered and complies with having fully equipped operation theatre of its own
wherever surgical operations are carried out.
c. If registered but other conditions are also found satisfactory on investigation
Resolution: Hospital definition is as per standard definition prescribed by IRDAI. It is clear
that registration with local authorities would not mean any authority such as Shops and
Establishment act. The authority should be the Clinical Establishment (Registration and
Regulation) Act, 2010 or under the enactments specified under the schedule of Section

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56(1) of the said act as stated below, otherwise, the authority is not deemed to be a
local authority.
“Section 56 (1) The provisions of this Act shall not apply to the States in which the enactments
specified in the Schedule are applicable:
Provided that the States in which the enactments referred to in sub-section (1) are applicable,
and such States subsequent to the commencement of this Act, adopts this Act under clause
(1) of article 252 of the Constitution, the provisions of this Act shall, subsequent to such
adoption, apply in that State.

THE SCHEDULE [See Section 56]

1. The Andhra Pradesh Private Medical Care Establishments (Registration and
Regulation) Act, 2002.
2. The Bombay Nursing Homes Registration Act, 1949.
3. The Delhi Nursing Homes Registration Act, 1953.
4. The Madhya Pradesh Upcharya Griha Tatha Rujopchar Sanbabdu Sthampamaue
(Ragistrikaran Tatha Anugyapan) Adhiniyam, 1973.
5. The Manipur Homes and Clinics Registration Act, 1992.
6. The Nagaland Health Care Establishments Act, 1997.
7. The Orissa Clinical Establishments (Control and Regulation) Act, 1990.
8. The Punjab State Nursing Homes Registration Act, 1991.
9. The West Bengal Clinical Establishments Act, 1950.”
If the registration authority is not mentioned within this section, then it is not a valid registration

48. Hospital Definition in states where Clinical Establishment Act is not

applicable.
Please find the following authorities that register a hospital/nursing home.
• Clinical Establishment Act is in the following states:
a. Bombay Nursing Home Act…for Maharashtra
b. The Andhra Pradesh Nursing Home Act
c. Delhi Nursing Registration Act
d. Orissa Registration Act
e. Punjab State Nursing Home Act
f. Manipur Nursing Home Act
g. Sikkim Nursing Home Act
h. Nagaland Healthcare Act
i. Madhya Pradesh Nursing Home Act
Other states do not have a Clinical Establishment Act or are working in creating one.
• In States with no Clinical Establishment Act, the hospital may be registered with the
following authorities:
j. Registration with municipal authorities (Shop & Establishment Act)
k. Registration for usage of Narcotic drugs
l. Certification for Bio Medical Waste

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m. Certificate against MTP/PNDT…applicable only in cases where there is a USG/ECHO

machine
n. NABH certification
o. ISO 9001 Certificate
Can we consider these as local authority certificates for registration of a hospital?
Resolution: No, it is not to be considered.

49. Registration of Hospital under Shops and Establishment Act in Gujarat

or states where Clinical Establishment Act 2010 is not in force
Resolution: Only Registration under Clinical Establishment Act shall be deemed as registration.
Registration under Shops and Establishment Act or registration for Sales Tax is not sufficient.
Where these do not exist, the criteria of minimum bed strength and staffing etc. must be met,
as per definitions (clause 2.15) already existing.
In Ahmedabad, the Bombay Nursing Home Act is valid for registration of hospitals as per the
following:
1. The Bombay Nursing Home Act (BNHA) 1949, has been adapted by the Gujarat
Government as a legal act in 1960; this was through a Government Gazette.
2. If a hospital in Ahmedabad is registered under Bombay Nursing Home Act (BNHA)
1949, then the registration is valid, provided the Bio Medical Waste (BMW) certificate
also is valid.
3. This registration certificate as per BNHA is valid for 5 years. The certification validity
ends if the hospital is no longer registered with the Gujarat Pollution Control Board
for BMW.

50. As per notification passed by Central Council of Indian Medicine

In 1996 under section 2 (1) Institutionally qualified practitioners of Indian systems of medicines
(Ayurveda, Siddha and Unani) are eligible to practice Indian systems of medicine and modern
medicine including surgery, gynaecology and Obstetrics based on their training and teaching
which are included in syllabus. Also high court has given decision to allow Allopathic practice to
Ayurvedic doctors in June 2008.
Can we allow claims of Ayurvedic doctors treating patients in hospital with modern medicines?
Or will this be treated as crosspathy?
Further an MS Ayurveda doctor is allowed to do surgery based on their training and syllabus. Can
we pay surgery claims of Ayurvedic surgeon? Also it is common practise for Ayurvedic/Homeopathic
doctors to engage in delivery of a new born baby. Can these claims be made payable?
Resolution: After studying the Integrated medicine course in Maharashtra, five procedures
are allowed to be practiced by AYUSH doctors. These practitioners obtain a Certificate to
perform a specific surgery in specific hospitals only.
We can allow such claims for a particular hospital on obtaining the certificate copy.
As per the Supreme Court Judgment in Poonam Verma vs Ashwin Patel Ors on 10 May 1996,
crosspathy is not allowed. Hence, for those doctors who have not undergone the additional
training in Allopathy, the claims involving allopathic procedures/treatment will not be admissible.

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System of Integrated Medicine as practiced in Maharashtra allows for the following:

a. Surgeries which are allowed by the cabinet for Allied Doctors ….these are any
surgeries in which they were trained on
b. Some of the surgeries are:
i. Cataract ii.
Tubectomy
iii.
Hysterectomy iv.
Hydrocele
v. Vasectomy vi.
Appendectomy
vii.
FTND

51. Ayurvedic treatment

In case of Ayurvedic treatment, SI is restricted to 25% but in most of the cases there are no
investigation reports in support of diagnosis.
Even some times looking at the condition of the patient from the symptoms/investigation
reports it becomes clear that hospitalization is not required and in such cases patient is enjoying
Mediclaim benefit.
Presently the percentage of this type of claim in increasing which is a matter of concern so far as
ICR is concerned and the matter should be taken up seriously to control the claim and to allow
only patients who require hospitalization.
Resolution: If the illness warrants hospitalisation irrespective of the system of treatment,
then the claim is payable. Hospitalisation Definition is to be followed.

52. Physiotherapist Registration Status.
Whether mandatory for reimbursement purpose?
Resolution: Not mandatory.

53. What should be the criteria for Physiotherapist fees in absence of

regulated tariff?
Resolution: No tariff can be prescribed. Reasonable and necessary expenses incurred can be paid.

54. Physiotherapy during post hospitalization period

should be paid as per
a. Limited no. of visits during the post hospitalization period
b. Only for a limited no. of days during the post hospitalization period of 60 days
c. Only if patient takes the treatment at the clinic irrespective of no. of days/ visits
d. If the patient takes the treatment at home under the support of prescription
Resolution: Revisions in policies cannot be made as policies are approved by IRDA.
Reasonable and necessary Physiotherapy expenses, if incurred at the Hospital, after discharge,
is payable up to sixty days, from date of discharge. If incurred at home, it is payable up to sixty
days from date of discharge if the Treating Doctor certifies that the condition of the patient is
such that he/she cannot periodically visit the Hospital for physiotherapy.

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Ophthalmic Procedures

55. Multifocal lens

Cataract payability – multifocal lens payability –If out of GIPSA how do we pay?

Resolution: Multifocal lens is not payable. Reasonable cost of unifocal lens can be paid.

56. Pre & Post Hospitalization Benefit for cataract.

In cases of capping e.g. Cataract which is RS 24,000 or 10% of SI, would this include the Pre &
Post hospitalization charges? The package cap ought to be for the primary procedure and not
the other charges.
Resolution: The cap is for the main claim as well as pre-post hospitalisation expenses.

57. Optho- Laser assisted cataract surgery

The sublimit for Laser cataract to be introduced or pay upto cataract sublimit plus the Laser
cost. Do we pay for the laser cost? 25%?
Resolution: Cataract capping will be applied. However in group policies where there is no
capping for cataract, restrict to conventional cost (MICS).

58. Femto Laser Cataract Surgery

The femtosecond laser technology that brought new levels of safety, accuracy and predictability
to LASIK flap creation is also advancing cataract surgery. The femtosecond laser applies laser
energy in an extremely short period of time, one trillionth of a second, so no significant heat is
generated (therefore, it is a “cool” laser). The reason cataract incisions are created in a two- or
three-plane fashion is so they will self-seal when surgery is complete, allowing for a no-stitch
approach. This is an advanced surgery for cataract.
Resolution: Payable. The expenses are to be restricted under the reasonable & customary
clause up to the extent of expenses of MICS (Micro Incision Cataract Surgery).

59. Admissibility of procedure YAG laser in ophthalmology

It is used in the following ailments:
1. Detachment of the nerve layer at the back of the eye (retinal detachment).
2. Swelling of the centre of the retina (macular edema).
3. Damage or displacement of the intraocular lens.
4. Bleeding into the front of the eye.
5. Swelling of the clear covering of the eye (corneal edema).
Resolution: YAG Laser in Ophthalmology will be considered as day care procedure and will
be paid in full.

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60. Lasik surgery

As of now we are paying claims for Lasik surgery if the refractive error of the patient is more
than +/– 7. Many Ophthalmologists are of the opinion that when Lasik surgery is done for power
of the eyes more than -9 dioptre the results are poor. What should be our stand on the same?
Resolution: To continue to pay for Lasik surgery up to a deficit of +/-7.0 dioptre or more in
vision. Lasik surgery is also included in day care list.

61. Intraocular contact lens

There are few cases where the patient has a high refractive index or power of eye but cannot
undergo lasik surgery as the outcome of that surgery is not satisfactory. Thus they are advised
to insert intraocular lens.
Resolution: Intraocular lens can be paid after waiting period of 4 years beyond +/-9.0 dioptre.

62. Strabismus surgery

Strabismus surgery is done both for correction of squint (cosmetic) and also to improve binocular
vision. All squint correction is NOT cosmetic, if done before amblyopia sets in, it can preserve
binocular vision. This surgery is considered medically necessary for children up to 10 years of
age, since such surgery can repair the vision impairment up to the age of 10 years. Beyond 10
years, it serves only cosmetic purpose. Hence, claims are to be paid for insured of 10 years of age
or less.
Resolution: Payable in children less than 10 years for vision defect greater than +/- 5 Dioptre.
Above 10 years claims are to be treated as cosmetic, hence not payable under Exclusion
no. 4.14.

63. Keratoconus- whether cataract capping is applicable?

Keratoconus is a degenerative disorder of the eye in which structural changes within the cornea
cause it to thin and change to a more conical shape than the more normal gradual curve.
Expenses are limited to Rs 24000 but it is not a cataract. When we try to restrict the claimant
argues that it is not mentioned in the policy. The treatment is costly which is up to Rs 75,000 to
80,000/-
Resolution: Cataract capping will not be applicable for Keratoconus. The treatment is
admissible as a day care procedure.

64. C3R with INTACHS for Keratoconus

INTACS are FDA approved used in cases of Keratoconus along with C3R, here we can apply
waiting period of 4 years especially in younger patients, however, it should be mentioned in
exclusion clause 4.3. INTACS and Holcomb C3-R® require little downtime and preserve vision,
causes the collagen fibrils to thicken, stiffen, and crosslink & reattach to each other, making the
cornea stronger and more stable & stopping the progression of Keratoconus disorder.
Resolution: Payable as day care procedure.

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65. Macular Edema and conditions associated with it .

Are these conditions payable?
Resolution: Payable as per policy terms and conditions, except for administration of
intravitreal injections in day care.

66. Is Inj Avastin payable in Diabetic Retinopathy under day-care?

These injections cannot be administered in OPD; specialized day care set up is required as topical
anaesthesia is given an injection is given thereafter under all aseptic condition in an Operation
theatre of any Eye clinic. When the foreign sites talk of the OPD procedures, they presume that
the conditions are aseptic and are equivalent to our day care centres. Intravitreal Injections
such as Avastin and Lucentis are prescribed even in premier institutes of our country such as
AIIMS.
Resolution: Not payable. Inj Avastin/ Lucentis/ Macugen or any other injections administered
through intravitreal route are not included in day care procedure for any illness.

67. Diabetic macular edema etc.

Policy clearly excludes the treatment of ARMD, what about the cases of Diabetic macular edema/
Proliferative diabetic retinopathy/ Macular edema secondary to central and branch retinal vein
occlusion? Hospitals are converting the administration of these injections into hospitalization.
Resolution: Any other treatment besides intravitreal injections will be admissible as per
other terms and conditions of the policy.
Inj Avastin/ Lucentis/ Macugen or any other injections administered through intravitreal
route are not included in day care procedure for any illness, hence not payable unless they
are required as part of the treatment along with any other procedure in which hospitalisation
is necessary. Not payable in pre or post hospitalisation.

68. Ozurdex Implant (intravitreal implant)

OZURDEX (dexamethasone intravitreal implant) 0.7 mg is a biodegradable steroid implant
injected into the eye (vitreous humour). It is FDA approved. Aetna considers Ozurdex
(dexamethasone intravitreal implant) medically necessary for the treatment of the following
indications:
• Macular edema secondary to branch (BRVO) or central retinal vein occlusion (CRVO)
• Non-infectious uveitis affecting the posterior segment of the eye
• Diabetic macular edema (DME).
Ozurdex is contraindicated and considered unproven in individuals with advanced glaucoma
and ocular or periocular infections.
Resolution: Not payable as intravitreal injections/implantation is not included in day care
procedures.

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Interpretation of policy terms and conditions

69. The limit for surgeries on bilateral organs
Scope of cover no. 2.1.1 vide Senior Citizen Mediclaim Policy & Extended Clause no. vide
Mediclaim Policy 2007
The limit for surgeries on bilateral organs or presenting on either side of human body (cataract,
hernia) should be specified in the policy as
a. Payable for both sides per year
b. Payable for one side only per year
c. Payable for both sides per year with cap on implants and surgeon charges
d. Should be limited to a certain % of SI with the liberty to use till limit exhausted
Resolution: Two claims are payable under one policy in case of bilateral organs.

70. Continuation of policy in migration

If insured is covered under another Ins. Co. & get migrated to New India prior to expiry of
previous policy, then the continuity should be considered or it should be considered as fresh
policy?
Resolution: If it is through portability, continuity is to be considered. In case of doubt please
seek clarification from operating office

71. Renewal of policy

If the policy is to be renewed for enhanced sum insured, then the restriction as applicable to a
fresh policy will apply to additional sum insured as if a separate policy has been issued for the
difference. In other words, the enhanced sum insured will not be available for an illness, disease,
injury already contracted under the preceding policy periods.
Challenges: In revised policies, the SI has been enhanced mandatorily to INR 100,000/-. If
insured had the lower sum insured in previous year & the illness was incepted in previous year,
what would the sum insured be applicable for this illness?
Resolution: Only the previous sum insured

72. Revised enhanced Sum Insured

Whether room rent restriction are applicable as per restricted Applicable SI or revised SI?
Example: Insured has continuous policy for last 10 years. Insured is covered under the Mediclaim
policy with Rs 50,000 for 4 years; post which he is asked to enhance the SI to INR 100,000.
He has been diagnosed with Osteoarthritis 4 years back which required Joint replacement
resulting in a claim of INR 150,000. As per policy Terms & condition clause no 6, the applicable
sum insured in the above claim is INR 50000/-
Challenge: Is the payable amount INR 50000/- or INR 100,000/-; since it was a mandate by the
Insurer, will the applicable SI change to the revised enhanced SI?
Resolution: For any disease contracted during the previous policy periods, the sum insured
would be restricted to the sum insured prior to enhancement.

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73. Cataract limit after migration

Query 1: Insured having current policy in New India floater with SI of Rs.200000/- , previously
policy under Mediclaim 2007 with SI of Rs.100000/-since 4 to 5 yrs, if claim occurred for cataract
what is the payable amount?
As per New India Floater policy, cataract limit is 10% of SI, Here applicable SI Rs. 100000/- as
enhance SI under two yrs. Waiting period. So, payable amount is Rs.10000/-
Or whether payable amount is Rs.24000/- as per cataract limit of Mediclaim 2007.
Query 2:      If insured having current policy under Mediclaim 2007 with SI of Rs.100000/- and
previously covered under Janata Mediclaim policy with SI of Rs. 50000/- since 4 to 5 yrs, if claim
occurred for Cataract then what is the payable amount?
Whether we pay Rs.24000/- as per limit of Mediclaim 2007 or we pay Rs.10800/- as per limit of
Janata Mediclaim policy,
Please guide us for above points.
Resolution: On any migration, the higher of the benefits available whichever is beneficial
can be given, only with respect to cataract. Thus, in both queries, 1 and 2, the insured will be
given the benefit of Rs. 24,000 for the cataract limit.

74. Tests done abroad

The NIA Clause states that the treatment has to be taken in India and payment in Indian
Rupees. There are certain tests where the patient is requested to get it done abroad though the
hospitalization is in India and payment made by the patient is in foreign currency.
Resolution: Tests undertaken overseas are not payable.

75. What is the Grace period for renewal of policy?

Resolution: 30 days subject to the condition that the disease/illness that incepted during the
policy break is excluded.

76. Domiciliary Hospitalization

Exclusion Clause 4.4.17 vide Mediclaim Policy 2007 and Family Floater Policy any Domiciliary
Hospitalization / Treatment is not payable. However with disputes arising in cases of post-
operative or elderly patients with orthopaedic problems
a. The clause need be revised for domiciliary treatment (ie. OPD) as not payable
b. Domiciliary hospitalization payable only if certified by the Dr. that patient is
incapacitated to visit the hospital and take the treatment
c. Both the above
Resolution: Our policy is clear that hospitalization with pre and post medical expenses are
payable. Domiciliary hospitalization is not covered.

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77. Cataract sublimit

Scope of cover no. 2.1.1 vide Senior Citizen Mediclaim Policy & Extended Clause no. f vide
Mediclaim Policy 2007 The cataract sublimit :
a. should be restricted to cataract surgery with post hospitalization treatment
Resolution: Yes
b. should be restricted to cataract surgery with post-operative complication leading to a
second hospitalization
Resolution: If second hospitalization reported after lapse of 45 days such may be
treated as fresh.

78. Application of Limits

Query: If any procedure or surgery is capped for specific limit (E.g. Cataract for Rs. 24000/-
or Normal Delivery for Rs. 25,000/-), then other limits like room rent limit & accordingly
proportionate deductions for entitlement etc. should be applied or not.
Resolution: Should be applied. Proportionate deductions should be first made. The amounts
so determined should be limited to the cap amount. Cap is the upper limit.

79. Janata / Senior Citizen Policy Procedure Capping:

In case of Janata / Senior Citizen Policy, there are two different types of capping, one is procedure
wise & another one is for Room, visit etc. Which one should be followed?
Resolution: First compute the charges as per the limits given for room/ICU/OT charges/
surgeons, anaesthetist, doctors’ fees, etc. incurred during hospitalization. Then the claim
amount may be capped as per the procedure wise/illness wise capping for specific illnesses
/ operations as per the policy.

80. Zone Capping:

Query: In case patient availing treatment in higher zone then the co-pay should be applied for
sum insured or Sum Insured & Cumulative Bonus. (Refer clause 2.10 of policy).
Resolution: It should be applied on sum insured and cumulative bonus.

81. Fraud Detection best practises to be implemented/shared for the

overall benefit of the Industry-
Resolution: Agree

82. Application of close proximity

It is found that many TPAs have not been informed about the close proximity rule and its
implementation – especially in respect of the accident cases. For accident cases Exclusion 4.2 –
30 days waiting period – is not applicable, the issue of Close Proximate is not being examined.
They should check not only the date of admission but they should check the date of accident
which should not be before the policy commencement date.
Many go by the DOA which should not be before the policy commencement date. Even if the DOA
is within the first 5-6 days, they have to investigate to find out the actual date of accident and
that the Insurance is prior to the occurrence of the event.
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Resolution: Agree, TPAs are hereby advised to ascertain the date of accident and the date
of admission. If either of these dates falls within 5 days of commencement of the policy,
they should get clearance from the insurer. It is not necessary that every such case needs
investigation. If the medical opinion of the TPA is that the Accident is unlikely to have happened
before Date of Commencement of the policy, there is no need for investigation. If there is a
possibility, in the opinion of the TPA medical team that the accident could have happened
before commencement of the risk, then the admission happened after commencement, such
cases need to be investigated and investigator’s clearance obtained. This will not apply to
group policies with pre-existing cover.

83. Enhanced Sum Insured Room Rent eligibility

As per clause 5.11 “In respect of any enhancement of Sum Insured, exclusions 4.1, 4.2 and 4.3
would apply to the additional Sum Insured from such date. “ Should the enhanced amount
be treated as a fresh policy and amount payable under room and ICU should be 1 and 2 %
respectively of the previous SI in case claim has a waiting period.
Resolution: The Room rent eligibility and applicable SI would also be restricted to a %
of Original Sum Insured in case the claim has a waiting period or is pre-existing. But if
the claim is for a disease contracted or an injury sustained after enhancement of Sum
Insured, the maximum amount payable and room rent eligibility would be governed by
enhanced Sum Insured.

84. Premium calculated on running age or completed age?

Age of the Patient Policy issued at age 60 and during the year the patient turns 61- Query:
Should we tell the insured to pay additional premium before the claim is paid? Or should we
apply co-pay @ 25% before paying the claim?
Resolution: No, completed age as at the time of commencement of the policy is the age to be
considered.

85. How to deal with cases having No intimation or delayed intimation

and delayed submission?
Resolution: At present we have given leeway to the TPAs to consider intimation within 72
hours and document submission till 15 days.
Beyond these limits please follow the guidelines as given below:
If the date of intimation is beyond 72 hours of the date of Hospitalisation OR date of submission
of documents is beyond 15 days, the TPA should:
a) Seek reasons for the delay from the Insured.
b) If it is convinced that the reasons for the delay are genuine, and that the claim
documents are in order, the TPA may send the file for condonation of delay to the
Policy Issuing Office.
c) If the TPA is not convinced with the reasons for the delay, or if the TPA has any
suspicion on the bona fides of the claim, it may get the file Investigated and
d) Present its findings to the Policy Office with its recommendation to condone the
delay or to repudiate the claim, as the case may be.

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86. Related Medical Practitioner

Policy Clause 3.6 defines MEDICAL PRACTITIONER means a person who holds a degree/diploma
of a recognized institution and is registered by Medical Council of respective State of India. The
term Medical Practitioner would include Physician, Specialist and Surgeon and shall not include
INSURED person and members of his family covered under this insurance.
Query: A Doctor visiting a tertiary care hospital & performing a surgery on his wife /children:
Is the claim admissible?
Resolution: Claim would be admissible but the charges relating to that surgeon would not
be admissible.

87. Do we pay Consultation/Visit charges of doctors

apart from hospitalization bill during hospitalization period to at least the amount of Rs
10,000/‐
Resolution: Only surgeon/anaesthetist charges as per proper numbered bill are payable;
apart from hospital bill for services during hospitalisation period.

88. If Patient is admitted in a hospital owned by their relative

either solely or in partnership?
Resolution: If the treating consultant/surgeon/assistant surgeon/ anaethetist is a relative,
then his fees will be deducted.

89. Contribution clause application

Insured has a New India policy as well as policies from other insurers. How to apply Contribution
clause 5.9 of Mediclaim 2012 for a claim?

5.9 CONTRIBUTION:
“If two or more policies are taken by You during a period from one or more insurers to indemnify
treatment costs, We shall not apply the contribution clause, but the You shall have the right to
require a settlement of Your claim in terms of any of Your policies.
1. In all such cases We shall be obliged to settle the claim without insisting on the
contribution clause as long as the claim is within the limits of and according to the
terms of Our policy.
2. If the amount to be claimed exceeds the sum insured under a single policy after
considering the deductibles or co-pay, the You shall have the right to choose insurers
by whom the claim to be settled. In such cases, the insurer may settle the claim with
contribution clause.
3. Except in benefit policies, in cases where You have policies from more than one
insurer to cover the same risk on indemnity basis, You shall only be indemnified the
Hospitalisation costs in accordance with the terms and conditions of the policy.”
Scenario 1) If the admissible claim amount is less or equal to the Sum Insured
Resolution: The insured has the right to choose any one policy to be utilized for the claim.
Contribution will not be taken from other policies. If the insured then approaches us for

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claiming the deducted amount, we are not liable for any payment. This is as per the IRDAI
guidelines interpretation of Contribution clause.
Scenario 2) The admissible claim amount is more than SI of the policy
Resolution: In this scenario the contribution is taken from other policies. The insured has
claimed from another insurer and is claiming the balance amount from our policy. Here
contribution clause will be applicable. The Settlement letter should be obtained from the
other Insurer or settling TPA stating that the amount settled is the full and final settlement
for the subject claim and the Insured is not eligible for any balance amount with respect to
this claim.
Example 1
 Policy 1(ICICI) Sum Insured: Rs. 4,00,000
 Policy 2 (New India SI): Rs. 3,00,000
 Claim amount: Rs. 6,00,000
 Settlement from ICICI: Rs. 3,50,000
 Balance amount: Rs. 2,50,000
Calculation:
 Claimed amount: Rs. 2,50,000
 We will adjudicate the claim for Rs. 6,00,000
 Non Payable amount= Rs 1.5 lakhs (including room rent deductions)
 Co-pay: 10%
 So our admissible claim amount is Rs.4,05,000
 Amount paid by Policy 1: Rs. 3,50,000
 So amount paid from our policy will be Rs. 4,05,000-3,50,000 = Rs. 55,000.
Example 2
In the above example, if the admissible amount under our policy is calculated to Rs 3 lakhs.
This amount is less than the claim amount paid by the ICICI, hence, we are not liable to pay
the claimant, since this will violate the Indemnity principle of health policy.
Example 3
 Policy 1(Videocon): Sum Insured: Rs. 4,00,000
 Policy 2 (New India): Rs. 3,00,000
 Claim amount: Rs. 3,50,000
 Co-pay in policy 1: 10%
 Settlement from Policy 1: Rs. 3,15,000
 Balance amount: Rs. 35,000
This co-pay amount cannot be paid from our policy.
Example 4
 Policy 1(Star) Sum Insured: Rs. 3,00,000
 Policy 2 (New India SI): Rs. 3,00,000
 Claim amount: Rs. 6,14,000
 Limit for Surgeon= 25%
 Limit for OT= 30%

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 Non Payable amount= Rs 2.14 lakhs

 Co-pay: 50%
 Settlement from Star: Rs. 1,26,000
 Balance amount: Rs. 4,88,000
Calculation:
 Claimed amount: Rs. 4,88,000
 We will adjudicate the claim for Rs. 6,14,000
 Non Payable amount= Rs 2.44 lakhs
 Our Admissible amount=3,70,000
 The amount payable after deducting Star settlement = 3.7-1.26 lakhs = 2.44 lakhs
 But the maximum liability from our policy = 370000 x 3 lakhs/(3+3)lakhs =185000
Hence Rs 1,85,000/- is payable from the New India policy.
In claims with capping such as maternity or cataract, the limit of capping is the effective
Sum Insured for calculation of proportionate amount.
Example 5
Insured has a total claim of Rs 1,15,000 for cataract surgery. She has a policy with Oriental of
SI Rs 5,00,000, the claim was paid up to the cataract limit of Rs 50,000 as per the settlement
letter. The Insured has lodged a claim for balance claim amount of Rs 65,000 from our
corporate policy. Our policy is of Rs 3,00,000 and the cataract limit is Rs 24,000.
 Policy 1(Oriental) Sum Insured: Rs. 5,00,000
 Policy 1(Oriental) Cataract Limit: Rs 50,000
 Policy 2 (New India SI): Rs. 24,000
 Claim amount: Rs. 1,15,000
 Non Payable amount= Rs 10,000
 Settlement from Oriental: Rs. 50,000
 Balance amount: Rs. 65,000
Calculation:
 Claimed amount: Rs. 65,000
 We will adjudicate the claim for Rs. 1,15,000
 Non Payable amount as per our policy= Rs 10,000
 Our Admissible amount=Rs 1,05,000
 The balance amount after deducting Oriental settlement= Rs. 55,000
 Our contribution for the claim= SI NIA/(SI NIA + SI Oriental) x NIA Admissible
amount = 24000/74000 x 1,05,000= Rs 34,054
Final Payable amount= Rs 24,000, since the Contribution amount Rs 34,054 exceeds our
cataract limit of Rs 24,000, hence we will pay up to the cataract limit.
Important Note: Regardless of the claim amount paid, if the claim is admissible we must pay
any benefits such as hospital cash or critical care benefit as per policy terms and conditions.

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90. Can the room rent eligibility be clubbed from policies of different
Insurers?
Resolution: The room rent eligibility cannot be clubbed from both policies of different Insurers.

91. Clubbing of two policies

Two policies in same policy period eg; one policy having sum insured of Rs.3,00,000/- other
policy having sum insured Rs2,00,000/- Can we club two policies for considering room rent and
other charges.
Resolution: Yes

92. Insured has 2 or more policies from New India. There is a claim for
cataract/maternity which exceeds the capping.
Should the claim be paid up to the capping of 1 policy or can we use two or more policies to pay
the claims?
Resolution: Limits of both/all policies can be combined if the claim amount exceeds the
capped limit.

93. Maternity Benefit: Both husband and wife separately covered under
our GMC Policy.
The claim amount exceeds permissible limit of wife. Can the balance amount be payable under
the spouse’s coverage?
Resolution: Yes, unless the policy limits the expenses to a family, i.e. husband and wife.

94. Claim during two policy periods:

In a claim the date of admission is in one policy period and date of discharge is in the renewed
policy period. If the claim amount or post hospitalisation expenses exceed the Sum insured of the
expired policy, can the balance claim amount be admissible under the renewed policy?
Resolution: Please refer to the IRDA notification dated 16th February 2013 at page no 84, under
s.no. 8, d (iv) which reads as follows –
MEDICAL EXPENSES INCURRED UNDER TWO POLICY PERIODS: 
“If the claim event falls within two policy periods, the claims shall be paid taking into
consideration the available sum insured in the two policy periods, including the deductibles for
each policy period. Such eligible claim amount payable to the Insured shall be reduced to the
extent of premium to be received for the renewal / due date of premium of health insurance
policy, if not received earlier.”
Resolution: If the claimed event falls in 2 policy periods and if the SI+CB of admissible policy
is exhausted in settling the admissible claim amount, then the sum insured of the renewed
policy can be considered for the settling the balance claim amount. However, the 1% room
rent eligibility of the two policy periods cannot be combined to take benefit of higher room
rent category. If the second policy is not renewed by the insured, then the TPA will deduct
applicable premium + service tax from the claim amount, remit it to the underwriting office
and settle the claim.

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95. Application of Co-pay:

Please advise which amount shall we considered as “admissible amount” on which co-payment
shall be applied: The total amount which is billed by the insured for his/her treatment and
assessed after application of deductions as per policy terms and conditions and arrived at a
figure more than Sum Insured.
Or the amount that becomes payable after deduction of non-payable items and application of
deduction of proportionate charges, it may be limited to the SI.
Resolution: The co-pay is to be applied on admissible claim amount before application of the
limit of Sum Insured.
To illustrate
Example 1: Sum Insured: 1 lakh
Total billed amount by the hospital: Rs.1,50,000
Compulsory co pay: 10%
Deductions: Rs. 25000
Calculation: Rs. 1,50,000-Rs. 25000= Rs. 1,25,000
Co-pay 10%.
So the admissible claim amount=1,12,500.
But our Sum Insured is 1 lakhs.
So our payable amount is Rs. 1,00,000.
Example 2: Sum Insured: 1 lakh
Total billed amount by the hospital: Rs.1,20,000
Compulsory co pay: 10%
Deductions: Rs. 25000.
Calculation: Rs. 1,20,000-Rs. 25000= Rs. 95,000
Co-pay 10%.
The admissible claim amount=Rs 85,500.
So our payable amount is Rs. 85,500.

96. Co-pay on sublimit

If the policy has co-pay and also sub-limit for an ailment, should we apply the co-pay on sublimit
or sanction up to sublimit?
Resolution: Apply co-pay on admissible amount and then sublimit. If after applying co-pay,
admissible amount is more than sublimit, sanction up to sublimit. Please check the policy
conditions, as co-pay may not apply in few policies, for procedures with sub limits.

97. Should we apply co-pay on PPN limit since it is already a negotiated rate?
Resolution: Yes

98. Cochlear Implant coverage.

Resolution: As per Clause 4.4.4, cochlear implant is an exclusion. Only the cost of implant is
not payable, but the cost of the surgery is payable.

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99. Sleep Apnea

Life threatening-- Hospitalisation is mainly for observation no treatment
Resolution: Self-explanatory, hospitalization merely for observation is not payable under
the policy.

100. Obesity & obstructive sleep apnoea

Need clarity on payability as Policy mentions Obesity treatment & its complications are not payable.
Resolution: If as a consequence of Obesity – not payable. Exclusion clause 4.4.15 of Mediclaim
Policy, 2007 excludes cost of instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P.)

101. Obesity treatment not payable—complication word applies to

obesity or obesity treatment
Resolution: Obesity and complications of obesity are not covered.

102. Bariatric surgery carried out in a lower than normal BMI individual
for uncontrolled DM….is this payable?
Resolution: If the claim documents specify BMI is below normal (25 or less) and there is
documented history of uncontrolled DM with medications, only then it is payable. Else it is
defined as treatment of obesity or its related complications. Only doctor’s certification that
surgery is required is not sufficient.

103. Heat/Cold Strokes/ accidental poisoning - are these accidents?

Will these be covered in the 30 days of policy period?
Resolution: Heat/Cold strokes not payable. Accidental Self poisoning is not payable, unless it is a
child below 14 years. However, if the accidental poisoning is due to external reasons, it is payable.

104. Psychiatric conditions in the presence of the disease like Vitamin

deficiency….is this payable?
Resolution: Psychiatric conditions are an exclusion in the policy, hence not payable regardless
of cause.

105. We are denying dentigerous cysts on the grounds that dental

treatment is not payable
unless caused due to accident. Dental cysts or tumours such as dentigerous cysts/ Keratocystic
odontic tumour/ odontogenic keratocysts/ ameloblastoma are not related to tooth decay or
gum infection.
These claims have also been repudiated on the same grounds although we specifically cover all
benign cysts and tumours after 2 years waiting period as per clause 4.3.1.8 of Mediclaim 2012
policy. Do we admit such claims?
Resolution: Any dental treatment not arising out of an accident is an exclusion. Only
malignancies are payable.

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106. Dental Implants

Please let us know whether to pay for implants in cases of fracture teeth as a result of accident
or there is a tooth disease etc when it is not done for the cosmetic purpose.
Resolution: Dental implants are excluded as per Clause 3.11 of Mediclaim Policy 2007
“DENTAL TREATMENT: Dental treatment is treatment carried out by a dental practitioner
including examinations, fillings (where appropriate), crowns, extractions and Surgery
excluding any form of cosmetic Surgery/implants.”
Hence, dental implants are not payable.

107. Hospital definition for dental treatment.

Accident occurred during policy period due to external, violent and visible means with
substantiating proof. It is not necessarily MLC/FIR but if it is for admission <24 hrs, it should be
dental surgery or fracture/dislocation excluding hairline fracture. Does this mean that hospital
should also fulfil the criteria of nursing home mentioned in policy conditions, since most of
dental hospitals are just clinics?
Resolution: The 24 hours hospitalisation for treatment of injuries sustained in the accident
should have taken place in a hospital which fulfills the criteria as per Hospital definition.
The definition for Day Care Centre applies where Dental treatment is included as day care
procedure in the policy, with the exception that the dental treatment can be undertaken in
a dental clinic run by a registered BDS/MDS practitioner and the requirement for Operation
Theatre may be waived off.

108. Gynaecomastia
Cases related to gynecomastia (enlargement of male breast) are mostly repudiated based
on cosmetic treatment. But mostly the clients tries to get the payment showing pathological
changes but their biopsy report does not justify any pathology. Still we have to pay the case
based on treating doctor’s note on the favour of the client.
Resolution: Not payable unless there is a clinical record of signs and symptoms of
malignancy or unilateral tumour mass supported by a positive histopathology report
and follow up treatment.

109. Acute Tonsillitis

As per clause 4.3.1, Benign Ear, Nose, Throat (ENT) disorders have a waiting period of two years.
Does this implies to Surgical management only or Medical management also (Eg: Acute Tonsillitis).
Benign, anywhere in the body, means that there is no implied threat to the body, like a polyp/
lipoma/wart etc.
Acute tonsillitis is a condition wherein treatment is required. In medical management the
treatment is IV antibiotics. In our opinion medical treatment for acute tonsillitis should be
covered as it is an acute infection however history of recurrent tonsillitis should be checked to
rule out pre-existing nature of illness.
Many times the insured is not aware that the disease is tonsillitis, they may avail treatment
under the impression that it is a throat infection which is covered under their policy.

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Resolution: All modalities of treatment for Benign Ear, Nose, Throat (ENT) disorders such as
Acute Tonsillitis are not payable during the waiting period.
The current policy guidelines (Mediclaim 2012) clause 4.3.1 mentions about the treatment of
illnesses and not procedures.
Hence the exclusion applies to both medical as well surgical management.

110. Skin disorder

No definite demarcation about skin disorder. If an acute infective skin lesion like carbuncle
occurs which has a definite bacterial pathology, can we relate this as a skin disorder? Skin
disorders have a two years waiting period.
Acute skin infections should be considered after 30 days of policy inception. Acute conditions
where definite infective pathology is evident, the skin disorders should be allowed without
waiting period. Those with ICD Codes L00 to L99 get covered under the waiting period.
Resolution: All benign skin disorders including acute skin infections are not payable during
the waiting period.

111. Hyperbaric Oxygen therapy

Hyperbaric Oxygen Therapy is recognized for few procedures like Non Healing Ulcer, Crush
Injury etc; whereas it is still experimental (unproven) in few other procedures like Acute Stroke,
Post Traumatic Head injury etc – what should be the stand be for such therapy?
The following uses of a hyperbaric chamber for HBOT have been cleared by FDA:
1. Air or gas embolism
2. Carbon monoxide poisoning
3. Enhancement of healing in diabetically derived illness such as diabetic foot, diabetic
retinopathy, diabetic nephropathy
4. Exceptional blood loss (anemia)
5. Intracranial abscess
6. Clostridal myositis and myonecrosis (gas gangrene)
7. Crush injury, compartment syndrome, and other acute traumatic ischemias
8. Decompression sickness
9. Necrotizing soft tissue infections (necrotizing fasciitis)
10. Osteomyelitis (refractory)
11. Delayed radiation injury (soft tissue and bony necrosis)
12. Skin grafts and flaps (compromised)
13. Thermal burns
14. Actinomycosis
15. Cyanide poisoning
16. Delayed radiation injury (soft tissue and bony necrosis).
These are considered to be proven uses of HBOT. For some of these conditions, HBOT is the
preferred treatment. For some others, HBOT is one of many treatment options to consider. For
other conditions the claim should be denied as unapproved / not proven/ experimental therapy.

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Resolution: Hyperbaric Oxygen Therapy may be payable during a hospitalisation for:

(1) Air or gas embolism
(2) Carbon monoxide poisoning
(6) Clostridal myositis and myonecrosis (gas gangrene)
(7) Crush injury, compartment syndrome, and other acute traumatic ischemias
(15) Cyanide poisoning
These conditions must be supported by additional documentary evidence other than the
doctor’s statement.

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Group policies
112. Organizational/ Corporate Buffer Floater
Specific approval from respective division is required or not. Various times we have to finalize
on Oral Approvals & cross mail confirmations.
Resolution: Please follow the advices of your underwriting office.

113. Group policy issues

We had come across a case under a group Policy where 4.1 and 4.3 were deleted but 4.2 was
retained and this policy had come to NIA for the first time. As there was misinterpretation,
queries were raised for Hospitalisation claims occurring in first 30 days including maternity,
Cataract etc. though there was no waiting period for them since the wording in 4.2 was deleted.
Resolution: This is a rare situation. Clarification may be sought from the operating office.

114. New born Baby coverage

New born Baby coverage queries and understanding is based upon clarifications given against
each of the policy by DO. Standard understanding needs to be set,
When baby is covered from day 1, it has to be by Endorsement, in which Endorsement effective
date has to be from date of birth of new born. Often Endorsement Effective date is after the
Date of Birth, if hospitalization is immediately after birth these claims become case on basis, on
approval given by respective DO only if the baby is covered from day one. Baby hospitalization
expenses other than well baby care to be considered as part of maternity limit. If only baby
covered from day one under floater limit. Then baby hospitalization arising out of any Ailment/
Diagnosis to be covered under Family Floater Limit.
Resolution: This is applicable to group corporate polices as a special benefit which is approved at
the time of proposal where premium is factored from inception of policy. Where baby is covered
from day one under family floater policy, floater S.I. is available for baby for any ailment/ illness.
Terms such as New Born Baby Coverage and Day One Baby Coverage could mean different
things, depending upon the scope of coverage under each Policy.
However, your suggestion to standardize the cover is welcome. Generally when Day One
Baby Cover is given, it is with a purpose to cover the new born right from day one, so that in
case complications arise at birth, they could be immediately indemnified, without waiting
for payment of additional premium or endorsement on the policy. Where such new member
entails payment of additional premium, such premium could be collected within the specified
time window. If any claim arises during the time window, the baby is covered without payment
of additional premium. In some cases new born baby is covered up to the floater sum insured,
or the sum insured available for the mother; in some cases it is covered up to the date of
discharge. It is, however, necessary to have the exact terms of coverage examined by referring
to the Operating Office.

115. Pre natal and post natal

Does Pre natal and post natal means pre and post hospitalization to the maternity claim
admission and duration to be considered?

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Resolution: Pre and post natal expenses means expenses incurred before and after the birth
of a child respectively. Maternity Benefit cover does not include pre and post natal expenses.
Maternity Benefit covers expenses incurred at the time birth of a child or at the time of
delivery, and hospitalization for complications related to pregnancy during the period of
gestation. (Refer Clause 7.5 of Group Mediclaim Policy, 2007)
If pre natal and post natal expenses are specifically covered they may be paid without
reference to the period of pre and post hospitalization.

116. Maternity Claim in Tailor Made Policy:

In a tailor made policy, if claim for maternity benefit in previous policy has been settled for
absolute limit, can insured avail maternity benefit in current policy also for same pregnancy?
This may happen if insured has hospitalized for some complications during pregnancy in
previous year & claim for the same has been settled. In current policy insured has claimed for
her Normal Delivery or LSCS. Can we give maternity benefit in both policies??
Resolution: No, expenses should be limited to the applicable limit for the same pregnancy.

117. What about the variants in maternity?

• Forceps delivery
• Vacuum Delivery
In policies, in policies, the clause usually says, for example:
• Normal Delivery: Rs 25000/- limit
• Caesarean Section: Rs 50000/- limit
Will limits apply to these or will the total SI be open for utilization?
Resolution: Forceps delivery and Vacuum delivery are variants of normal delivery hence
normal delivery capping will be applicable.

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Maternity complications and Infertility

118. Endometriosis in scar – post LSCS.
Any time limit for the same to include under maternity capping or exclusion? Current process:
sequel of maternity, coverage subject to maternity coverage.
Resolution: It is applicable in group policies, where there is a maternity benefit. This incident
occurs after 45 days of LSCS; such claims are considered as new and paid within the maternity
capping, if available.

119. Endometriosis waiting period

Exclusion clause 4.3 states a waiting period of two years for “Hysterectomy for Menorrhagia/
Fibromyoma, Myomectomy and Prolapse of uterus.” In case indication for hysterectomy is
endometriosis, will it be admissible?
Also if uterine prolapse is treated by suspension treatment will it be admissible?
Resolution: The waiting period stated is for three sub-conditions:
a) Hysterectomy for the two specific named conditions- Menorrhagia and Fibromyoma. If
the condition for which hysterectomy is stated to be done is endometriosis one first needs
to satisfy that it must be deemed “necessary”, usually by a stated accompanying intractable
menorrhagia (then automatically, named exclusion applies) or intractable pain, in which case
duration of same and possible repudiation under pre-existing clause may be possible. In the
absence of evident pre-existence of that complaint and with documentation/investigation
reports to show intra-mural or uterine peritoneal surface endometriosis (for endometrium
exists normally as lining of uterus, it must exist abnormally to constitute endometriosis),
such rare cases may be payable at the discretion of TPA after the waiting period of 2 years.
b) Myomectomy has a similar waiting period,
c) Prolapse Uterus in toto, as a diagnosis, has exclusion for the said waiting period, hence
any surgery for the same, whether hysterectomy or suspension, would remain non-payable
within that period.

120. Hysterectomy for conditions not mentioned in 2 yr waiting period,

for example Adenomyosis
Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus are not covered in the
first two years of the policy.
So the conditions are becoming more specific. For example, Adenomyosis. It is the same as
Fibroid /Leiomyoma /Myoma except that it is contained within the walls of the uterus. Hence
hysterectomy (removal of uterus) and other gynaecological surgeries if arising due to any other
condition is payable.
It will have a very negative impact on the ICR. Hence need to review this policy condition with
utmost emergency.
There is one more situation where the application of the exclusion is avoided by resorting to
‘Myomectomy’ for which there is no waiting period! We cannot deny such a claim without
assigning any policy clause as IRDA would levy a penalty.

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Resolution: Adenomyosis is a variation of fibromyoma/myoma and will have associated

menorrhagia. Hence, it will not be payable before two years waiting period. Myomectomy is
a treatment for fibromyoma/myoma, hence the two year waiting period will be applicable.

121. Uterine Septum

Uterine Septum causes infertility; its removal will promote conception. Should it be considered
non payable under infertility or should be paid under internal congenital disease? Septate
Uterus does not cause any major problem to the person and does not require any treatment.
It is not considered necessary to remove a septum that has not caused problems, especially in
women who are not considering pregnancy. Hence, any treatment is only to ensure prevention
of miscarriage and carrying the pregnancy to its full term.
Resolution: Treatment of septate uterus would qualify to be fertility/ sub-fertility treatment,
hence not payable.

122. Hysterectomy followed by delivery in placenta previa

Hysterectomy may be done at the time of delivery or LSCS, due to uncontrollable bleeding.
Women who have placenta previa are also more likely to have a placenta that’s implanted too
deeply and that doesn’t separate easily at delivery. This is called placenta accreta.
Placenta accreta can cause massive bleeding and the need for multiple blood transfusions at
delivery. It can be life threatening and may require a hysterectomy to control the bleeding.
These conditions can sometimes be confirmed by ultrasound, CT scan, or MRI. In this case can
we give hysterectomy charges in individual policy? Since we have already covered hysterectomy
under the policy conditions, emergency hysterectomy done due to excessive bleeding after
delivery or LSCS can be made admissible after the 2 year waiting period is over.
Resolution: Hysterectomy will be payable in if performed during or soon after delivery/
LSCS for placenta accreta/increta/ percreta and life threatening uncontrollable bleeding. No
waiting period.
Indications for Hysterectomy in Post-Partum Haemorrhage(PPH)
Hysterectomy following Post-Partum Haemorrhage(PPH) is admissible in the retail Mediclaim
policy and the group policy up to eligible Sum insured subjected to other policy terms and
condition for the following indications of Hysterectomy due to PPH
1. Atonic Uterus following delivery despite of conservative management
2. Ruptured Gravid uterus: Ruptured Gravid Uterus for any reason other than Illegal abortions.
3. Large cervical laceration extending into the uterus resulting in PPH
4. PPH where medical management is unsuccessful. These included arterial
embolization, balloon tamponade, uterine compression sutures, and iliac artery
ligation or uterine devascularisation.
5. Cesarean delivery for placenta previa carries a relative risk of 100 for peripartum
hysterectomy, with many patients having a diagnosis of placenta accreta.
6. Sepsis: In the era of modern antibiotics, sepsis is not a common reason for emergency
hysterectomy. However, it still may be necessary in cases with extensive uterine
sepsis, particularly with clostridial infections and myometrial abscess formation, in
which antibiotic treatment fails to control the infection.
7. Retained Placenta not responding to other surgical management

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123. Complication secondary to LSCS surgery

For example, patient develops internal bleeding after undergoing LSCS for which she has to
undergo an explorative laporotomy.
The internal bleeding is a complication of the surgery done and not a complication of the
maternity itself. In such case, is the approval to be limited to Maternity limit or can the full SI
be utilized?
Resolution: Not payable in a retail policy. The maternity limit applies as it is a sequelae/
complication of a surgery needed only for the existing maternity.

124. Can we consider other life threatening conditions like Rectus

sheath hematoma during pregnancy
apart from ectopic pregnancy to be included in the policy?
Resolution: Maternity related complication, hence not payable.

125. Hysteroscopy with biopsy

Should Hysteroscopy with biopsy be considered as curative or diagnostic?
Resolution: Hysteroscopy with biopsy is a diagnostic procedure, hence not payable.

126. Ectopic pregnancy

As per Clause 4.4.13 we can pay “Extra uterine pregnancy (Ectopic Pregnancy), which is proved
by submission of Ultra Sonographic Report and Certification by Gynecologist that it is life
threatening one if left untreated.”
How about the cases where the patient is admitted with acute pain in abdomen and there is no
time for doing Ultrasound and emergency laparotomy which shows evidence of rupture of the
tube (ruptured ectopic pregnancy). This is recorded in the OT notes. Can we pay such claims
without the ultrasound report? Can we consider the OT notes and certificate from the treating
doctor regarding the same.
Resolution: We will admit such claims if the first consultation papers and/or OT notes
are available and document evidence of ectopic pregnancy symptoms such as tachycardia,
bleeding, pain and histopath report confirming the diagnosis.

127. For ectopic pregnancy the limit available is Maternity limit or

available sum insured?
Resolution: General Sum Insured for surgical and conservative treatment. For conservative
treatment USG is compulsory along with Certification by Gynecologist.

128. Incisional Hernia arising out of LSCS

Hernia is usually covered after two years of coverage. However, in the case of Incisional Hernia
arising out of LSCS, it would be payable after forty eight months of continuous coverage. As per
resolution given in previous compliance queries, incisional hernia post LSCS can be covered
after 48 months. Can we cover this even if maternity is not covered?

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Resolution: Yes- Incisional Hernia arising out of LSCS can be covered after the 2 year waiting
period is over for hernia. If the Caesarean-Section is pre-existing, then 4 years waiting period
for pre-existing conditions will apply.

129. Infertility -Fibroid uterus, ovarian cyst; evaluation or/and

treatment for non-admissible diseases like infertility
Fibroid uterus, ovarian cyst are common cause of infertility. Frequently we find cases wherein
the member is trying for conception. USG shows presence of fibroid/ovarian cyst and undergoing
treatment for the same. Should we approve the case based on pathology or take infertility into
consideration?
When any evaluation or/and treatment for non-admissible diseases like infertility may end up
in diagnosing admissible disease which may be asymptomatic or symptomatic, but admissible
under our policy, such as chocolate ovarian cysts or pelvic kidney. Then treatment (surgical/
medical) for the admissible disease will be payable or not?
Resolution: If the procedure is linked to infertility then it is not payable, for example,
procedures such as ovarian drilling/cautery for PCOS/PCOD or myomectomy in absence of
symptoms are not payable.
If the claim is for myomectomy/ovarian cyst with complaints of pain and/or menorrhagia,
supported by documentary evidence, then the standalone procedure is payable.

130. Thermal balloon ablation

Surgeries like TBEA (Thermal Balloon endometrial abalation). We shall limit the charges up to
hysterectomy or Hysteroscopic resection.
It is more cost effective than a hysterectomy. The degree of severity and persistence of the
menorrhagia and the failure of prior treatment should be such that the member would otherwise
be a candidate for a hysterectomy. Should it be included in day care? The procedure takes about
45 minutes.
Resolution: It is not a day care procedure. The cost will be restricted to conventional
hysterectomy charges by applying reasonable and customary clause.

131. Embolisation of uterine artery

Uterine artery embolization is procedure where an interventional radiologist uses a catheter to
deliver small particles that block the blood supply to the uterine body.
The procedure is done for the treatment of uterine fibroids and adenomyosis. The minimally
invasive procedure is commonly used in the treatment of uterine fibroids it is also called uterine
fibroid embolization.
The procedure is performed by a Vascular Interventional Radiologist under local anesthesia.
Access is commonly through the radial or femoral artery. A guiding catheter is commonly used
and placed into the uterine artery under x-ray fluoroscopy guidance.
Resolution: Payable only in malignancy of uterus. Not a day care procedure.

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Accidental Injury /Self harm

132. Religious fasting, Toxicity/ poisoning due to self-medication
Should these be paid? Or can be considered as self inflicting injuries? Religious fasting should
not come under self harm but self medication is not permissible under law unless patient himself
is a doctor.
Resolution: Self-medication will be payable unless it is proven to be suicidal such as overdose.
Any adverse reaction after any medication is payable.
A claim for fasting is payable unless it is suicidal.

133. In case of consumption of Dettol/ benzodiazepam/ phenyl or burn
cases where no MLC is done by the hospital.
Doctor mentions accidental history, whether we can accept such claims?
There are 20 conditions in which MLC is mandatory:
1) All injury cases, circumstances of which suggest commission of offence by someone.
2) All burn injuries due to any cause.
3) All vehicular, railway, aeroplane, ship, boat, factory, construction site or other
unnatural accidents where there is likelihood of death or grievous hurt.
4) Suspected or evident homicide, suicide including attempted.
5) Suspected or evident poisoning.
6) Suspected or evident sexual assaults.
7) Suspected or evident criminal abortion.
8) Unconscious cases where the cause is not natural or not clear.
9) Cases brought dead with improper history creating suspicion of an offence.
10) Cases referred by Courts or otherwise for age estimation.
11) Dead on arrival cases, or patients who die shortly after being brought to the Casualty
and before a definite diagnosis could be made.
12) Any other case not falling under the above mentioned category but has legal
implications.
13) Patients dying suddenly after parenteral administration of a drug or medication.
14) Patient falling down or any mishap in the Hospital, sustaining injury in the Hospital.
15) Death on Operation table.
16) Unexplained death after surgery or Interventional procedure.
17) Unexplained ICU death.
18) Patient treated and then referred from a private hospital or other Government hospital
with complications of surgery or delivery or bleeding, where the cause of death is
unexplained.
19) Relatives of the patient assault the treating doctor or other staff of the hospital.
20) Relatives of the patient create a law and order problem in the hospital.
Resolution: These cases should be investigated and MLC should be asked. If MLC is not
available, justification from the treating doctor is required for not MLC. However, for condition
no. 3, MLC need not be insisted upon unless the nature of injuries is serious.

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134. Accidental injuries in the first 30 days after inception of policy.

Please let us know whether or not we can pay the claims of the accidental injuries in the first 30
days in the revised policies, where the clause 4.2 od Mediclaim 2012 policy is silent. It was part
of clause 4.2 in the earlier policies.
EXCLUSION CLAUSE 4.2 “Any Illness contracted by the Insured person during the first 30 days
of the commencement date of this Policy. This exclusion shall not however, apply if the Insured
person has Continuous Coverage for more than twelve months.”
Resolution: Accidental injuries are payable in the first 30 days after policy inception unless
the accident took place before inception. Clause 4.2 is silent because it specifies only Illness,
a term defined vide clause 2.17 and not Accident- defined vide clause 2.1. This means that
Accidental Injuriy during the first 30 days are not excluded.

135. Accidental bodily injury to minor for driving two / four wheeler
Whether akin to deliberate exposure to danger and violation of regulations, should it be handled  
as per policy condition 4.4.7? Engaging in an illegal/unlawful activity should be excluded. The
proximate cause in this is against the law.
Resolution: Payable.

136. Injury as a result of active participation in any hazardous sports

Does horse riding in a city, climbing stairs at any pilgrimage place fall under this category?
Which sports as in Leisure or Professional fall under this clause? As participation in active
hazardous activity involves consent of the Insured voluntarily the same cannot be considered.
Deliberate ignoring of ordinary precautions to safeguard oneself from harm must be established
in order to deny under this clause.
Resolution: Agreed that rejection under this clause can be resorted to only in extreme sports
cases where there is a deliberate, wilful and conscious choice by the insured to expose himself
to dangers not usually associated with normal sports activity.

137. Use of Tobacco leading to cancer

For example, Carcinoma Lung- Smoking; Carcinoma oral cavity- Tobacco chewing. What is to be
done in such type of cases? Where documents are submitted for Carcinoma mouth/ tongue etc.
and habit/history of tobacco chewing for many years. The person may have left the habit since
few months / years and now the person is suffering from Cancer. Here no document is available
from hospital mentioning tobacco is the cause / leading factor of cancer in particular patient.
Can we categorically deny the claims attributing to smoking, tobacco chewing etc. as proximate
causes?
Resolution: In Mediclaim 2012 and newer policies where the exclusion for use of tobacco is
deleted, hence we cannot deny such claims. In other cases, if there is a direct causal
link of cancer of lung/buccal mucosa, claim can be denied.

138. Pancreatitis or cirrhosis of liver with past history of alcohol

Person has stopped taking alcohol for last one year. He is now suffering from pancreatitis or
cirrhosis of liver. Whether we should to correlate with alcohol?

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In most cases, acute pancreatitis is caused by  gallstones  or heavy alcohol use. Other causes
include medications, infections, trauma, metabolic disorders, and surgery. In up to 30% of
people with acute pancreatitis, the cause is unknown.
In about 45% of people, chronic pancreatitis is caused by long-time alcohol use. Other causes
include gallstones, hereditary disorders of the pancreas, cystic fibrosis, high triglycerides, and
certain medicines. In about 25% of cases, the cause of chronic pancreatitis is unknown.
Damage to the pancreas from heavy alcohol use may not cause symptoms for many years, but
then the person may suddenly develop severe pancreatitis symptoms.
Chronic Alcoholism has a known association with Cirrhosis of Liver and Pancreatitis.
Even if there is an abstinence from alcohol for a year the pathological changes have already
occurred and are not reversible. Hence the same cannot be considered.
Resolution: If there is a direct causal link of history of alcohol intake to cirrhosis/ pancreatitis,
claim can be denied.

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Congenital Disorders
139. Development Dysplasia of HIP
According to recent study, the ailment earlier known as ‘congenital dislocation of hip’, previously
classified as a congenital disorder has now been classified as developmental disorder. Please
clarify the admissibility under “congenital external clause”?
Resolution: If birth notes pick up and mention the defect, or other documents mention
congenital origin/diagnosis, then deny. Otherwise, it remains payable as if it were
Developmental subject to other terms, conditions and exclusions under the policy

140. Indirect Inguinal Hernia

Indirect Inguinal Hernia which is a congenital anomaly has a patent opening through which
abdominal contents herniate. Normally it closes at birth, but presents in case of chronic cough
or respiratory distress. Many auditors classify this under ‘Congenital External’, but most of the
times it is ‘Congenital Internal’. Indirect Inguinal Hernia or even the ‘Congenital Hernia’ is due
to non-closure of the patent duct. In many cases it is not visible in the newly born ones unless it
is very pronounced.
Resolution: The condition may be present from birth. But at the time of claim, if the condition
is in accessible and visible part of the body, then it is congenital external, but if it is not in
visible and accessible part of the body then it is congenital internal.

141. Inguinal Hernia in a child aged 3 yrs
Logically it seems to be congenital external disease but treating Doctor gives a certificate that it
is not congenital and has duration of few months. What should we do in such cases?
Resolution: At the time of claim, if it is not manifesting, then it is internal otherwise external.
After 5 years of age and after continuous coverage of two years, it is payable even though it is
Congenital External.

142. Congenital Cataract

To be considered congenital external or internal?
Resolution: Congenital External. A list of congenital external disorders is attached in
Annexure III.

143. Spina Bifida

Some congenital external ailments like Spina Bifida and hydrocephalus though visible externally
is a developmental defect requiring a lot of medical attention in babies. Spina bifida is an
congenital external condition we recommend to consider this treatment where ever baby is
covered from day one. Spina Bifida may be covered by skin & hence not visible externally. This
should be considered as internal.
Resolution: Congenital External

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144. Undescended Testis/Congenital External

Should we should consider undescended testis as external congenital or not? External congenital
–definition according to IRDA: Congenital External Anomaly means a Congenital Anomaly
which is in the visible and accessible parts of the body.
Resolution: External Congenital

145. ArterioVenous malformations

Should we pay for Arteriovenous malformations which are visible from outside?Whether it is to
be considered as congenital external?
Resolution: To be considered External Congenital if clearly visible from outside.

146. List of Inherited and Acquired Genetic Disorders

Clause 4.4.16 states that genetic disorders are excluded. My query is does it include both
inherited and acquired genetic disorders? Need to define genetic disorders word correctly to
avoid confusion. Few examples of genetic disorders:
• Polycystic Kidney Disease
• Crohn’s Disease
• Cystic fibrosis
• Down Syndrome
• Hemophilia
• Neurofibromatosis
• Polycythemia Vera
• Porphyria
• Thalassemia
Resolution: All the genetic disorders that are recurring will not be payable.
The following conditions, though genetically inherited or acquired, will be payable as an
exception, since most are poly factorial in nature:  

• Tumours: Malignant and Benign • Myelodysplastic Syndrome

• Leukemias and Lymphomas • Osteoporosis
• Cardiac Valvular Diseases • Cataract
• Cardiac Septal Diseases: ASD, VSD, PDA • Arthritis
• Autoimmune Diseases • Sarcoidosis
• Glaucoma • Tetrology of Fallot
• Gullian Barre Syndrome • Ulcerative Colitis
• Retinopathies • Asthma
• Aneurysms • Hypertension
• Multiple Sclerosis • Diabetes Mellitus Type 2
• Motor Neurone Diseases • Inflammatory Bowel Disease
• Mixed Connective Tissue Disease • Infertility
• Myasthenia Gravis
• Multiple Myeloma
A general list of genetic disorders not covered is attached in Annexure IV for your
reference.

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147. Admissibility of stem cell treatment claims:

We have been considering the claims for stem cell transplantation for cancer and related
illnesses like Hodgkin’s Lymphoma, Multiple Myeloma etc.
However we would like to draw your attention to the fact that at present, there are no approved
indications for stem cell therapy other than the hematopoietic stem cell transplantation (HSCT)
for haematological disorders. Accordingly all stem cell therapy other than the above shall be
treated as investigational and conducted only in the form of a clinical trial after obtaining
necessary regulatory approvals. Use of stem cells for any other purpose outside the domain of
clinical trial will be considered unethical and hence is not permissible.
Thus, Hematopoietic Stem Cell Transplantation (HSCT) for patients with certain cancers of
the blood or bone marrow, such as multiple myeloma or leukemia is an approved course of
treatment.
In view of the ICMR Guidelines, we would request you to review your decision so that the
settlement could be restricted to Hematopoietic Stem Cell Transplantation (HSCT) for patients
with certain cancers of the blood or bone marrow, such as multiple myeloma or leukemia.
Resolution: Agree with the suggestion to define the wordings. We restrict the admissible
stem cell therapy to the subset of hematopoietic stem cell transplantation (HSCT) for certain
cancers of the blood or bone marrow, such as multiple myeloma, leukemia or lymphoma.

148. Donor Expenses:

Donor Charges in the case of an allogenic transplant: ‘Donor Charges’ or organ harvesting
expenses are admissible only in cases of Organ Transplants
Stem Cell Transplant does not amount to organ transplant and hence, not admissible. Kindly let
us know whether this stand is right
Resolution: Stem cells are a permanent exclusion. Donor expenses for Harvesting of
bone marrow (hematopoietic stem cell transplantation (HSCT)) are payable if the claim is
admissible.

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Claim Adjudication
149. Reasonable charges for Diagnostics
Clause no. 2.4 vide Mediclaim Policy 2007: For relevant Laboratory/Diagnostic test, X-Ray under
the Mediclaim policy, Usual, Customary & Reasonable charges can be enforced by:
a. Fixing limits for Metro and non- metro cities
b. Proportionate linking to room rent
Resolution: No. Policy provides only for ‘reasonable, customary and necessary expenses’
and payment can be regulated by this provision.

150. Proportionate deduction of Implants

Whether proportionate deduction as per the entitled room category is applicable on Implant
charges under section Note-1 of clause 2.0
Resolution: No.

151. Accidental fall

Clause# 4.2: Will a fall at home leading to a fracture/head injury be construed as an accidental
fall?
Resolution: Yes

152. Artificial Limbs

Artificial Limbs are generally not fitted within the Post Hospitalisation and at times done after
many months. There will not be any other expenses other than Artificial Limb expenses. How
to treat such cases? We also feel that the policy wording should change from “replacement of
Artificial Limb should not be considered” to “Artificial Limbs for the first time within 6 months
of amputation”.
Resolution: Agree. This may be taken as our special sanction for payment of artificial limbs
for the first time, within six months of the date of discharge, provided the cost towards such
limbs is reasonable.

153. Decision for reasonable and customary deduction

Any deduction on the basis of Usual, Customary and Reasonable Charges
a. Should be with the concurrence of the Insurance Co. in writing for each and every
claim
b. May be a sole TPA decision
c. Should be considered as with the concurrence of the Insurance Co. as long as grievance
is not lodged
Resolution: TPA can decide on its own. Insurer has a right to overrule, if warranted.

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154. LOS (length of stay) to be specified

LOS (length of stay) to be specified as per categories of diagnosis and levels as per complications
- Should be relaxable for complications if properly described and treatment details given or
-Cannot be specified and is left to the best judgment of the treating Doctor
Resolution: No. We cannot lay down specific length of stay. TPA may look into the merits and
decide.

155. Proportionate deduction in Breach Candy

In some hospitals like Breach Candy Hospital or Belle View Hospital- charges for Consultation,
Surgeon, Asst. Surgeon, Anaesthetist, investigations etc. do not vary according to Room Rent. In
such scenario should we apply proportionate capping or not?
Resolution: In Mediclaim 2012 policy and newer policies the clause states that:
“3.1 (d) In case of admission to a room/ICU/ICCU at rates exceeding the aforesaid limits, the
reimbursement/payment of all other expenses incurred at the Hospital, with the exception
of cost of medicines, shall be effected in the same proportion as the admissible rate per day
bears to the actual rate per day of Room Rent/ICU/ICCU charges. “
Hence in these policies proportionate deduction is to be applied if the admission is to a higher
than eligible room/ICU/ICCU, irrespective of the hospital tariff across room categories.
In Mediclaim 2007 policy, if the Hospital Authority has issued a letter stating that the other
charge does not vary as per class of accommodation, then the TPA must inspect the hospital
SoC, and past bills. If the TPA is satisfied that there is no variation of any charges across room
categories, no deduction need be made. The spirit of this deduction is to compute, as nearly
as possible, the total cost that would have been incurred, had the patient stayed in a room
that he is eligible for, and to restrict our claim to that computed cost.

156. Case of eligibility of the room category

What is the stand in the following: If eligible room category is not available in hospital and even
a general ward is at a higher rate than eligible?
Resolution: Proportionate deductions would apply, wherever the room availed is at a higher
rent than eligible. Any reasons given such as no vacancy, no room in that rent slot, etc. is not
to be considered.

157. Verification of proposal form in case of pre-existing illness

Auditors are making recoveries or wanting us to refer the cases to branches, DO and RO even
when the policy is running 5th or 6th year of continuous renewal, in case it has been observed
that there is some chronic ailment, duration of which is more than 8-10 years. As per the new
definition of Pre Existing Disease and the exclusion clause 4.1 and applicability of exclusion
clause 4.1, in case, the patient has continuous coverage and 48 months (claim free) have elapsed,
we don’t think we can apply exclusion clause 5.1 and 5.8 which is also reproduced below along
with definition of Pre Existing Disease and exclusion clause 4.1.
Clause 2.31 “PRE-EXISTING CONDITION/DISEASE: Any condition, ailment or Injury or related
condition(s) for which you had signs or symptoms, and/or were diagnosed, and/or received
medical advice / treatment within 48 months prior to the first policy issued by the insurer.”

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Clause 4.1 “Treatment of any Pre-Existing Condition / Disease, until 48 months of Continuous
Coverage of such Insured Person have elapsed, from the Date of inception of his / her first Policy
with Us as mentioned in the Schedule.”
Clause 5.1 “BASIS OF INSURANCE:This Policy is issued on the basis of the truth and accuracy
of statements in the Proposal. If there is any misrepresentation or non-disclosure We will be
entitled to treat the Policy as void.”
Clause “5.8 FRAUD, MISREPRESENTATION, CONCEALMENT:
The policy shall be null and void, and no benefits shall be payable in the event of misrepresentation,
misdescription or nondisclosure of any material fact/particular if such claim be in any manner
fraudulent or supported by any fraudulent means or device whether by the Insured Person or by
any other person acting on his/her behalf.”
We do not give any chance to the insured to fill a new proposal form where in the insured could
have declared any disease which was Pre-existing at the time of his first proposal.
Resolution: If the discharge summary/claim documents declares history of 7-8 years for any
illness, then we will consider it as 7 years history.
All diseases having a waiting period are covered after waiting period is over. Hence, after
completion of waiting period we do not ask for proposal form if there is no mention of related
pre-existing disease.
For illnesses arising after 4 years of continuous coverage, we will not ask for proposal form
unless it is one of the 11 critical illnesses. If the claim is related to any of the 11 critical
illnesses as per IRDA definition:
• Ask for proposal form filled at the date of inception of first policy or at the
time of enhancement from underwriting office. If underwriting office declares
that the proposal form is not available or if there is no response within 10
working days, then claim can be settled.
• If the proposal form is available, and the illness or its related risk factors are
declared or the form is left blank, then settle the claim.
• If the proposal form is available, and the critical illness or related risk factors
are declared as not existing, then reject the claim under clause no. 5.1 and 5.8.
Diseases in the first 2 years of the policy, proposal form is to be asked from underwriting office,
unless the disease is clearly not pre-existing such as an acute infection or accidental claim.
Between 2-4 years of continuous coverage, if the claim papers hint at a condition pre-existing
up to 4 years before the first inception of the policy or enhancement of the SI, then ask for the
proposal form.
Implant removal for a pre-existing fracture is payable after 4 years without asking for proposal
form.
For any mention of pre-existing history of Diabetes and/or Hypertension, the proposal form
is to be asked.
Obtaining the proposal form:
In case of doubt about pre-existing condition, the TPA has to ask the proposal form from the
Underwriting Office keeping the Health Manager in copy. The UW office has to reply within
10 working days. If the UW office does not reply within 10 working days, then the TPA has
the liberty to go forward.

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158. Clarity of Diabetes and Hypertension related disorders

There is no waiting period for DM and HTN in the present Mediclaim 2012 policy. Even if DM
and HTN is pre-existing, diseases arising out of them as a complication like coronary artery
disease, IHD cannot be restricted as these conditions are declared within the policy period by
the treating doctor. Thus it requires proper clarity regarding these 2 diseases HTN and DM and
disease complications arising out of them.
Resolution: In claims for diabetes mellitus type 2 and/ or hypertension which are clearly
not pre-existing, but have arisen after inception of policy, the claim may be settled in policies
where there is no waiting period.
Where there is a pre-existing history of DM/HTN in any claims of Diabetes and/or Hypertension
or related ailments such as cardiac or kidney ailment:
1. Does the policy show loading for DM/HTN or declaration of the pre-existing ailment?
i. If yes, and
a. Is there 48 months of continuous coverage?
1. If yes, settle the claim.
2. If no, do the claim documents clearly establish that the admission was
directly related to Diabetes and/or Hypertension or these conditions were
the cause of the ailment?
i. If yes, repudiate the claim under pre-existing clause.
ii. If no, settle the claim.
ii. If no, deduct the loading for the applicable years up to 31st July 2013 and follow the
steps in point 2.
2. Is there a direct correlation between the hospitalisation/ailment and DM/HTN as per
claim documents:
i. If yes, ask for the proposal form from UW office as per previous resolution.
a. If no response from UW office for 10 working days/proposal form not available/
declarations left blank in proposal form, then settle the claim.
b. If proposal form is available and the insured has declared absence of pre-existing
ailments/diabetes/hypertension, then repudiate the claim on non-disclosure of
material facts. The policy is to be cancelled.
Diabetes and Hypertension are the contributing conditions for many ailments which may
also have other causes such as Coronary Artery Disease and Kidney Failure, so a direct
correlation may be difficult to establish. So pre-existing condition of DM and HT should not
be held responsible for cardiac surgeries. In such cases 4 years waiting (pre-existing) will not
be applicable to Cardiac surgeries.
If a person is suffering from any chronic illness (cardiac/kidney/diabetes type 1 etc) at the
time of proposal, then do not accept the proposal itself.

159. If migrated from 2007 to 2012 and loading paid for 2 years, then
will 50% and 75% be payable?
Resolution: Yes

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160. Waiting period for Diabetes and Hypertension

Exclusion clause 4.3 in Mediclaim 2007 and Senior Citizen policies has a waiting period for
Diabetes and Hypertension during which these conditions shall not be covered. Shall this waiting
period apply to those ailments as well where Diabetes and Hypertension are major risk factors
such as Coronary Artery Disease?
Resolution: Most cardiac ailments such as Coronary Artery Disease, Ischemic Heart Disease
usually have no linear relation only to Diabetes and/or Hypertension. Therefore, a claim for
these conditions during the waiting period for diabetes and/or hypertension are admissible
unless:
• The claim papers show that the ailment/hospitalisation was directly due to
diabetes and/or hypertension
Diabetes and HT does not necessary result in Cardiac surgeries. So pre-existing condition of
DM and HT should not be held responsible for cardiac surgeries. In such cases 4 years waiting
(pre-existing) will not be applicable to Cardiac surgeries.

161. How to define reasonable and customary?

As per the earlier policies, it was easy for us to apply the policy term of medically necessary,
Reasonable and customary. However, now, it is not easy to convince your own development
officers/agents/brokers/ombudsman/consumer courts etc while adjudicating the claims as per
the revised terms.
As per the current definitions, it is difficult to refuse a claim for the newer treatment like Robotic
Surgeries, green light lasers, cobalt tonsillectomy, etc, the list is endless. These treatments
are no longer experimental, but are indicated in many situations with comorbidities and/or
complications.
For example, in a claim of robotic surgery for cancer, the claimants argue that the rates for
robotic surgery paid in their claim are reasonable and customary as compared to rates in for
robotic surgery similar hospital for a similar ailment. The Ombudsmen/Consumer Court takes
a similar view.
Resolution: Necessary, customary and reasonable is the maximum amount considered
eligible for reimbursement under the policy. This amount will be determined based on the
review of the prevailing charges made by physicians/surgeons for a similar health service
within a specific community or geographical area.
For example, if 10% are charging 1 lakh or more and 90% are charging 80,000/ or less for the
same service and in the same geography, then the maximum covered amount will be 80,000/
or less.
TPAs are to use the claims data available with them to give examples to Ombudsman. They
may compile a database comprising a minimum of 500 claims. Compare the rates and decide
on the reasonable rates for any procedure.
In common procedures, the reasonable and customary limit can be defined by the limit fixed
in PPN packages for a similar hospital in the same geographical area.
For new types of treatment: deny based on all available grounds such as 24 hrs, day care,
experimental etc.

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162. Hepatitis B and Hepatitis C infection and related Complications

Payable or not.
Resolution: The claim for Hepatitis B and C is payable if the complications of infection require
more than 24 hour hospitalisation, unless etiology is STD. However, the administration of
drugs like Pegasys do not require hospitalization.

163. Ebola infections are payable or not

Resolution: The claim for Ebola is payable if the complications of infection require more
than 24 hour hospitalisation. Vaccination or hospitalisation for isolation is not payable.

164. Tumour is present before HIV infections

In New India Floater Mediclaim Policy under clause 2.8.’Critical Illness’   2.8.1 cancer exclusions
“All tumours in the presence of HIV infections are excluded.” My query is if a tumour is present
before HIV infections?
Resolution: If the tumour is present before HIV, then it is payable. Kaposi’s Sarcoma will
not be payable. There are few cancers directly related to presence of HIV/AIDS. These are:
Kaposi’s Sarcoma, Non-Hodgkin’s Lymphoma and Cervical Cancer.

165. Some STDs which may have other routes of transmission like blood
transfusion payable or not?
Since it is difficult to establish the source of the STDs, it is better to deny the claim keeping in
view the policy exclusion in the policy.
Resolution: Not payable. In case the Discharge Summary or ICP clearly states that transmission
was due to blood transfusion or congenital, than the claim can be considered as per policy
terms and conditions.
For example, congenital Syphillis of baby will be considered as congenital ailment. Because of
strict rules for testing and transfusing blood, it is very rare to acquire any STD/Infection from
blood transfusion.

166. Plastic Surgery in cases of accidents

Will it be payable in case there is no primary complaints?
Resolution: Plastic surgery necessitated due to accident or any illness or cosmetic/aesthetic
surgery due to burns or illness will be admissible if the causative condition was also admissible
under our policy. The correction will be admissible up to the pre-ailment status.

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Administration of medications in day care

167. Anti Rabies Vaccination
Exclusion clause 4.4.3 excludes vaccination and inoculation, whereas under day care treatment
anti rabies vaccination has been allowed, both appear contradictory.
Resolution: Anti Rabies vaccination is explicitly included under 3.4. Exclusion 4.4.3 excludes
vaccination and inoculation. But since Anti Rabies Vaccination is specifically covered under
3.4, to that extent the exclusion 4.4.3 does not apply to Anti Rabies Vaccination.

168. Oral chemotherapy

Anti-cancer drugs [Chemotherapy drugs] like Methotrexate, Cyclophosphamide, Blenoxane,
L-Asparaginase, Leuprolideacetat etc.  are at times are given as intramuscular or orally. Are
they admissible?
Resolution: Not payable unless it is in pre/post hospitalisation od an admissible claim.

169. Inj Rituximab

Rituximab (trade names Rituxan, MabThera and Zytux): Though non payable it is given in rare
autoimmune conditions and also needs continuous monitoring ‐ should we change to consider
it in the list? Rituximab was approved by the FDA to treat B-cell Non-Hodgkin Lymphomas
resistant to other chemotherapy regimens. Also, FDA-approved for use in combination with
methotrexate (MTX) in adult patients with Rheumatoid Arthritis (RA), who have had an
inadequate response to one or more anti-TNF-alpha therapy. Rituximab is administered only as
an Intravenous Infusion. It would qualify to be covered under daycare.
Resolution: Not a day-care procedure. Payable if part of chemotherapy/ radiotherapy/ or
related hospitalisation. Payable in Pre/post hospitalisation expenses of an admissible claim.

170. Infliximab/Remicade, Enbrel/ Etanercept therapy

Remicade (infliximab) is used to treat Rheumatoid Arthritis, Psoriatic Arthritis, Ulcerative
Colitis, Crohn’s Disease, Ankylosing Spondylitis, and Severe or Disabling Plaque Psoriasis.
Remicade is injected into a vein through an IV. This medicine is usually given at intervals of 2 to
8 weeks. After administering injection Remicade, a close monitoring of the patient is required to
watch out for side effects, especially for the first infusion.
On case to case basis we seek approval from the insurance company. Also, if patient
needs continuous infusion on consecutive days then claim should be considered under
hospitalisation.
ENBREL (etanercept) is a prescription medicine that can be self-injected. It is used to treat
five long-term inflammatory diseases: rheumatoid arthritis (RA), plaque psoriasis in patients
who are candidates for systemic therapy or phototherapy, psoriatic arthritis, juvenile idiopathic
arthritis (JIA), and ankylosing spondylitis (AS). As this is self-injectable one, it does not require
hospitalisation and can be denied.
Resolution: Not a day-care procedure. Payable if part of related hospitalisation. Payable in
Pre/post hospitalisation expenses of an admissible claim.

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171. Inj Botox

Inj Botox is used for hemi facial spasm/spasticity which may be contribute to disability of the
patient. Can we consider the same under day care and pay in case of specified symptom list.
Resolution: Injection Botox is not payable.

172. Intra articular injections

Such as Methylprednisolone, Triamcinolone, Betamethasone, Hyaluronic Acid etc.
In medicine, a joint injection (intra-articular injection) is a procedure used in the treatment of
inflammatory joint conditions, such as rheumatoid arthritis, psoriatic arthritis, gout, tendinitis,
bursitis, Carpal Tunnel Syndrome and occasionally osteoarthritis. A hypodermic needle is
injected into the affected joint where it delivers a dose of any one of many anti-inflammatory
agents, the most common of which are corticosteroids. Hyaluronic acid, because of its high
viscosity, is sometimes used to replace bursa fluids. The technique may be used to also withdraw
excess fluid from the joint. The administration of these injections can be done as an out-patient
procedure. Can be considered if done under C arm.
Resolution: Not a day-care procedure. Payable if part of related hospitalisation. Payable in
Pre/post hospitalisation expenses of an admissible claim.

173. Zolandronic acid (aclasta) therapy

Injection Zolandronic acid (Zometa/Reclast/Aclasta) is an IV injection is used in Cancer with
metastasis in bones. This is not a chemotherapy but supportive treatment in cancer. It is also
given in various conditions for prevention or treatment of osteoporosis.
Resolution: For multiple myeloma, it is payable even as day care as an exception. Not a day care
procedure for any other ailment. For other hospitalisation, it is payable if it is part of some other
treatment. It is payable in pre and post hospitalisation expenses of an admissible claim.

174. Herceptin: (Traszutumab)

It is a targeted therapy for HER2 positive metastatic cancer in breast and stomach. It may be
given in combination with chemotherapy or alone after chemotherapy. It is administered in the
hospital as an IV infusion and has almost the same side effects as any other chemotherapeutic
agent such as heart failure, nausea, vomiting, allergic reactions, etc. We recommend it should
be included as a Day Care procedure
Resolution: Not a day-care procedure. Payable if part of chemotherapy/ radiotherapy/ or
related hospitalisation. Payable in Pre/post hospitalisation expenses of an admissible claim.

175. Injection Falsodex

Injection Falsodex (Fulvestrant) is a hormonal drug used for Estrogen Receptor positive
metastatic breast cancer in menopausal women. It is given as an intramuscular injection. It also
has the same side effects of chemotherapy with an additional risk of difficulty in breathing and
respiratory failure…should be considered a day care procedure. Currently it is payable if given
along with other chemotherapeutic agents
Resolution: Not a day-care procedure. Payable if part of chemotherapy/ radiotherapy/ or
related hospitalisation. Payable in Pre/post hospitalisation expenses of an admissible claim.

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Suggested Daycare Procedures

176. Treatments usually done on OPD or Day care basis and being
converted to IPD.
Resolution: Only those specified procedures qualify as Day care and none else. If the treatment
relates to the diagnosis and treatment of a positive illness, and if the stay exceeding 24 hours
is warranted, it is payable. If it falls under the ‘Note under clause 2.16.1’ of the Mediclaim
2012 policy, it is not payable.

177. Arthroscopy
Earlier, arthroscopic procedures required stay for more than 24 hours, however, now the
therapeutic arthroscopies should be payable in day care
Resolution: Arthroscopy is payable as day care procedure if there is a positive diagnosis,
only in reimbursement claims. No cashless will be given for arthroscopy.

178. Implant/DJ stent removal post 60 days

Should we consider under Day Care?
Resolution: Can be included as day-care.

179. Hospitalisation for Epidural block

Whether Hospitalization for Epidural block/Facet block followed by traction to be considered
in disc prolapse? Can Facet blocks/Epidural injections are used in debilitating back pain be
considered as a day care procedure?
Resolution: Can be considered as day care procedure.

180. Reduction and Strapping for Clavicle Fracture

The vast majority of clavicle fractures heal with non-operative management, which includes the
use of a simple shoulder sling. Fracture/dislocation excluding hairline fracture is considered by
you under day-care procedures. Closed reduction and strapping or application of a sling does
not require hospitalisation. It could be done in an ortho clinic. Even if it is done in a hospital they
issue only an OPD Bill as the hospitals in India have only two types of Bills - IP & OP Bills. Is this
payable under day-care/ hospitalization?
Resolution: Already included in day-care except for hairline fracture. OPD bill and papers
can also be admissible in a day care procedure, provided that all the required patient and
treatment details are mentioned.

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Diagnostic Procedures
181. How to deal with CT guided Angiography
CT angiography does not require the use of a large vessel for injection and is an outpatient
procedure. Conventional CAG and CT angiography procedures both require the injection of
contrast but patients who undergo CAG are usually admitted overnight and the complication
rates (bleeding, hematoma, emboli) are higher compared to CT angiography.
It can be done in a Diagnostic centre equipped with CT equipment and thus does not require
to be done only in a hospital. Further, no follow up procedures are carried out by the Surgeon
based on the CT Angio. The patient will be subject to conventional CAG again and therefore, this
is an unwarranted procedure and purely diagnostic one. We should deny the claims under (a)
Purely Diagnositc (b) Does not require hospitalisation & (c) not a reasonable, necessary and
customary procedure like Conventional CAG.
Resolution: Payable only in Pre/post hospitalisation expenses of an admissible claim. Not
a day-care procedure. Not payable if Conventional CAG was also paid for in the same claim.

182. MRI
a. Should not be paid under hospitalization without any active treatment and a normal
report
b. Should be paid as an integral part of treatment wherever it is the only conclusive test
for diagnosis of a disease Eg. PIVD provided it is done within 30 days prior to related
hospitalization
Resolution: Refer Exclusion 4.4.11 of Mediclaim 2012 Policy:
“Charges incurred at Hospital primarily for diagnosis, x-ray or Laboratory examinations or other
diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive
existence or presence of any Illness or Injury for which confinement is required at a Hospital.”
Hence, payable wherever it is consistent with or incidental to the diagnosis of a positive
ailment for which hospitalisation is required.

183. Admission for PET SCAN?

Resolution: Not to be considered in day care. Payable in Pre/post hospitalisation expenses
of an admissible claim.

184. Can we settle a claim in case there is positive diagnosis but there is
no active treatment?
Resolution: No, if there is diagnosis, it would usually be followed by treatment. If there were
no treatment, it could come under exclusion 4.4.11:
“Diagnosis, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis
of positive existence and treatment of any ailment, sickness or injury, for which confinement
is required at a Hospital/Nursing Home.”
In this clause, the words “diagnosis of positive existence and treatment” would imply that
treatment should follow diagnosis. Else, the tests would become inadmissible. If, however,

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such diagnosis was followed by treatment in a Hospital within thirty days, they would become
admissible under Pre Hospitalization expenses.

185. Diagnostic procedures done to evaluate the condition of patient

Whether Diagnostic procedures such as Tru cut biopsy for prostate/ renal biopsy/ check
cystoscopy in CA Bladder / Liver Biopsy are admissible?
Resolution: Payable as day-care procedure only for biopsy of vital organ where the diagnosis
is positive. It is payable only on reimbursement basis.

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Process Related Queries

186. Clarification on repudiated file
a. Who will send the repudiation letter to insured, whether TPA or Insurer?
Resolution: TPA with a prior approval of draft by Divisional Manager.(Follow the
attached Circular No. HO/HEALTH/2012/IBD:ADMN:31 dated 19th July, 2012)
b. Repudiated files will be stored at TPA office or U/W office?
Resolution: At TPA office and wherever it is necessary, the files will be called from
the TPA.

187. CB confirmation from DO

In Indore we were instructed by D.O.1 & D.O.2 that we should not ask for CB confirmation and
previous policy copies, whatever is written on the policy must be treated as confirmed. Should
we follow the same?
Resolution: Confirmation of policy details from Operating Office is required only if there is
confusion regarding the same.

188. Delay condonation confirmation

Whether delay condonation confirmation from the respective policy issuing office is
required in a case where we are receiving re-open request from the Insured after a lapse of more
than 2 months?
Resolution: Yes. Any request for reopening the claim should be approved by the office
concerned.

189. What are the issues which are encountered with regard to 64 VB?
Resolution: Policy extract is uploaded to TPA systems every day. It is assumed that 64 VB has
been complied with. The U/W office will give a list of policy where 64 VB was not complied
due to cheque bounce.
If a claim is received in the first 45 days after first inception or renewal of the policy,
the TPA has to verify 64 VB with the concerned office. After 45 days have passed, verification
is not required.

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Documents Deficiency
190. Separate bill for professional fees
Nursing homes, commonly Polyclinic, they do have practice of billing everything excluding
professional fees. How to deal with such billing? Similar in case of Anesthetist. They always
provided separate receipt.
Resolution: Please be guided by Clause 3.9 of Mediclaim 2012 Policy.

191. Pharmacy receipts (FDA), retail and In-house pharmacy.

Resolution: Medicines used during hospitalization should be supported by prescription and
cash bills.

192. Batch number and expiry dates are not available

Confirmation on admissibility of medicine charges where batch number and expiry dates are
not available in the hospitalization bill.
Resolution: Unless there is reason to suspect the bonafides of the claim, there is no
need to insist on batch numbers and expiry date for routine drugs which are consistent
with the treatment undertaken, and duly supported by prescription of the treating
Doctor. However, if the cost of the drug is high, we should insist on Batch Numbers and
Expiry Date.

193. In-house pharmacy

Doctor’s prescription: The hospital has an in-house pharmacy, hence does not have medical
prescriptions and cash bills. These claims may also be for surgical cases from bigger hospitals,
would request that we ask for details only in cases of conservative and not surgical.
Resolution: In case of in-house pharmacy, prescription is not required. But batch number and
expiry date is mandatory. However the TPA needs to satisfy themselves that the medicines
are in-line with the treatment. For outsourced pharmacy, or outside pharmacy, prescription
is mandatory.

194. Verifying documents from non-network hospitals

This refers to wordings under Condition 5.4 of Mediclaim Policy 2007 Physical Examination:
Any Medical Practitioner authorized by the TPA / Company shall be allowed to examine the
Insured Person in case of any alleged disease/illness/injury requiring Hospitalization. Non-co-
operation by the Insured Person will result into rejection of his/her claim.
At times Non-Network Hospitals and Government hospitals doesn’t permit us to verify their
documents then how to resolve the issue?
Condition 11.0 of the Policy states:
“The insured may also be required to give the Company/TPA such additional information and
assistance as the Company/TPA may require in dealing with the claim.”
Resolution: If the Hospital does not provide any information that the TPA requires for
adjudication of the claim, the TPA should send a letter or mail to the insured, under this

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Condition 11.0, seeking his authorization to the Hospital for providing such information.
If the insured fails to give such authorization, even after a reminder, such an act would
be treated as non-cooperation, and the insured would have to be notified that such non-
cooperation would entail rejection of the claim under 5.4 of the Policy.

195. Few auditors are insisting of X ray and CT scan plates in each case
The patient needs these for further treatment as no duplicate plates can be prepared. We are
insisting for original reports which are sufficient proof for diagnosis and patient can keep
photocopy of same for further treatment. We request you to clarify on requirement of X-ray /
CT plates.
Resolution: X-ray plates are required in all the cases. If the X-ray is not there then digital copy
is required. If the customer has requested for return of plates for further treatment, in such
cases the TPA needs to take a photograph and keep a print-out (A-4 paper) in the claim folder.
In cashless cases X-ray plates are not required, only report would suffice.

196. Stickers and invoices of Implants

In case of orthopaedic surgeries like ORIF, CRIF wherein screws, nails are used ranging from Rs
4000/- to Rs 50,000/- . Whether sticker is mandatory even if invoice is given?
Resolution: Stickers and Invoice are mandatory in cases of orthopaedic surgeries such as
TKR/THR. If any orthopaedic implants do not have stickers such as screws and nails, the
invoice in the name of the patient should be available with the details of the implant, such as
supplier, make and model. For implants above Rs 5000 in value, post operation X-ray in which
the implants are seen will be required in the claim file.

197. Claims received from rural areas:

In rural areas proper documents like discharge summary and proper formatted hospital bill
are not available even after queries. Can we consider such documents on hospital letter head
if signed and stamped by hospital and if a proper receipt of payment is available? Further
sometimes even payment receipts are a part of the hospital bill.
Since these hospitals do not maintain printed Bills & receipts, authenticity is not there. The
Company can think of settling such claims on non-standard basis.
Resolution: The discharge summary should have the doctor’s stamp and registration number.
It should be on the hospital letter head and have the information required for adjudication
of claim.
Original printed and numbered bills with hospital stamp are mandatory. The receipt may
be part of the bill, or on the hospital letter head but it should refer to the bill number. If the
original receipt is lost, then investigation should be done.

198. In Government hospitals photocopy of discharge summary and
reports are provided to patients
The original documents are retained by hospital for further treatment. This is more often
observed in hospitals like Tata Memorial, etc. Earlier we would accept the photocopies, However
as mentioned above different auditors take different stands whilst auditing. Kindly clarify.

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Resolution: Photocopy duly certified (signed and stamped) by the hospital can be permitted
if they are Government Hospitals or major cancer Hospitals.
Hospital Bills must be original for all the Hospitals.

199. No name of the patient mentioned on the Indoor Case sheets
It is difficult to judge whether they belong to the same patient.
Resolution: If the ICP sheets have IP number, with the treatment details in line with the
treatment and patient details, then it is acceptable. But if there is no IP number and no name,
then not acceptable. In such cases, the genuineness is in doubt. Even the courts will not accept
them as valid documentary evidence.

200. Payment of Doctor’s fees by Demand Draft

Whether to be treated as per cash basis for claim settlement purpose.
Resolution: Demand Draft to be considered as equal to cheque.

201. Admission seems for mainly investigation purpose

Patient is admitted for 2-3 days; during the stay only some diagnosis procedure done like GI scopy
or Thoracosopy is done and patient is administered some IV fluids with antibiotic cover only
for remaining days. Such cases can be paid or not as admission seems for mainly investigation
purpose?
Resolution: This has to be decided on a case to case basis. If there is no active line of treatment,
then the claim is not payable.

202. Cases of negligence on the part of treating Doctor

wherever established in treatment documents. Whether the claim is to be settled obtaining
subrogation form? What procedure is to be followed for subrogation?
Resolution: Claim will not be put for subrogation.

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Day-care Procedure related queries

203. Day care surgeries in non PPN Hospitals
Package rates are given which are very reasonable but no bifurcation. Few hospitals are not
providing the same. How to apply 2.1, 2.3, 2.4?
Resolution: Compare the package rate for same surgery in the PPN hospital of the same
category, and if found to be lesser than such PPN rates, pay without application of 2.1, 2.3,
2.4. This applies only for day care procedures, since the period of stay is less than twenty four
hours.

204. Death case hospitalization less than 24 hours, Chest pain –

hospitalization less than 24 hours.
Resolution: To pay

205. Decision of Day care procedure

Power of discretion should be with TPA Medical Panel and Insurer should not object the same,
w.r.t. utmost good faith. Follow Clause 3.4.
Resolution: Any day care procedure to be included would be only with the specific approval
of the insurer.

206. Fracture on OPD basis

According to day-care procedures as per 2.16.1 in Mediclaim 2012– In cases of fracture/
dislocation, except hairline fracture, person goes to the hospital on OPD basis cast is applied.
Can we consider this as a day care treatment?-
Resolution: We can consider on OPD if brief case history is given by treating doctor. The
waiver in all day care procedures is for both 24 hours hospitalisation and IPD details. Hence,
daycare procedures as listed in policy will be permitted in OPD. The name and details of
patient, treating doctor, date/time of admission and discharge, diagnosis, history, treatment
given and follow up will have to be mentioned on the OPD papers.

207. In cases where CAG is normal

Treatment is only for observation of further complications…..will this not be payable?
Resolution: CAG is an exception. Even if there is no finding, it is payable.

208. Should one day of stay be payable for any day care procedure?
If the patient stays for more than 24 hours for a Day care procedure such as cataract, then
should the hospital be treated as per definition hospital and not a day care centre?
Resolution: If the treatment is only for day care such as cataract, then treat it as day
care procedure, irrespective of length of stay. One day stay charges may be admissible. If
the treatment is something more than day care treatment, then consider it as normal
hospitalization and follow the given hospital definition.

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209. If the procedure is not mentioned in the list, even of Mediclaim

2012, then does it still remain a Day Care procedure?
Does this require Insurance Company approval? Eg. Bronchoscopic removal of foreign body,
Gastric Varices ligation, Endoscopy, Coloscopy, Vitrectomy, etc.
Resolution: Any procedures not mentioned in policy wordings of day-care will not be
considered as day care without specific approval from New India Assurance. Vitrectomy and
Retinal detachment are day care procedures. All the procedures given in New India Floater
may be followed for Mediclaim 2012, Mediclaim 2007 etc.
Endoscopy or Colonoscopy are not considered as day-care procedures. These will be
considered in pre/post hospitalisation or as part of an admissible hospitalisation.

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Deductions in claim
210. Discuss list of surgeries where assistant surgeon is required.
Resolution: Surgeries such as Appendicectomy – Open/ Laparoscopic, Hernia - Femoral /
Inguinal unilateral, Incisional Hernia - Mesh Repair, Hernia – Laparoscopic, TURP, Cystoscopy,
PCNL require assistant surgeon. A list of the common surgeries where assistant surgeon is
required, is given in Annexure I.
For surgeries other than these whenever an Assistant surgeon is billed for, one must examine
the OT notes. If the need for assistant surgeon is established, then it can be paid.
In case, there are any intra operative (iatrogenic) complication during surgery there might
be requirement of assistant surgeon in order to treat the same , that also can be considered
depending on the details provided by the hospital.
The services of assistant surgeon might also be required in certain cases where there
is any rupture of an organ other than the system on which the surgery was already being
performed. e.g. bladder injury in case of  hysterectomy. In this case, the additional surgeon
will be required.

211. How to decide when IC and TPA do not agree about requirement for
assistant surgeon?
Resolution: Insurer’s decision will be final.

212. If there is fever, fall, stone associated with Maternity

The claim is in individual policy. Bifurcation is not available, how to deal with it?
Resolution: If the admission to the hospital (illness) is independent of maternity in an
individual policy, then we can pay. But if it is related to maternity, then it is not payable.

213. Pre and post hospitalization benefit

Medicines of chronic illness are payable or not. Medicines may be or may not be linked to present
illness.
Resolution: If the medicines are related to healing of the illness, then we will pay. If the
medicines are not related to the treatment at all, then we will not pay.

214. Surgical Cases: Cotton, Betadine, Gauzes, Syringes, needles ….are

these payable?
Resolution: Payable as per reasonable and customary use.

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PPN issues

215. If bill break-up is provided in GIPSA cases, whether NMEs should

be deducted?
Resolution: Payment can be effected up to package rate.

216. Whether there is any sublimit or capping in GIPSA packages?

Providers frequently collect over and above amount in GIPSA cases quoting that only say 5000
was limited to Pharmacy head, in case it is above that the same will be charged extra.
Resolution: No. Providers cannot charge extra except for complications and co morbidity.
Deviations should be brought to the notice of the lead TPA and lead insurer.

217. PPN Hospital Discount

Should it be applicable on admissible amount or final hospital bill, as there are different auditor
views in this matter.
Resolution: Hospital discount is applicable on admissible amount, not on total hospital bill.

218. In Cashless hospitalisation many grievances are received for GIPSA

packages.
Claimant is eligible for Deluxe room as policy is for Sum Insured Rs.8 lakhs and they get cashless
benefit for twin sharing or single room only. They request for revision of GIPSA packages.
Resolution: The Insured is eligible for Single AC room PPN package if the procedure is
included in the PPN packages. If it is not a PPN procedure, then the insured can occupy a
room as per the eligible room rent category. The hospital SoC will be applicable in such cases.

219. In case of partial PPN procedure/ more than one surgery in single
admission / complicated cases
What should be our criteria for payment?
Two PPN procedure in single admission.
Resolution: Second procedure 50%, along with supporting positive documentation for
requirement of second procedure.
One PPN procedure, other non PPN procedure in single admission.
Resolution: PPN procedure charged as per eligible package. Breakup to be asked for the non-
PPN procedure along with supporting positive documentation for its requirement. Calculate
the charges which will be in addition to those already included in the PPN package.
Complicated cases
Resolution: Charges in complicated cases or co-morbidities can be paid as per hospital SoC
in addition to those already included in the PPN package as per supporting documents. The
need for extra charges has to be supported by positive documentation.

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220. Co-morbidity or complex cases in PPN

In case of co-morbidity or complex cases in GIPSA PPN hospital, hospital is deviating from PPN
package and extending hospitalization stay. But in some cases the PPN hospital charges over
and above the GIPSA PPN Package without any Co-morbidity or Complexity.
Resolution: Ask for supporting justification for the co-morbidity/complexity- if satisfied
than we can consider.

221. PPN Hospital not providing breakup of medicines

Hospitals like Kokilaben are not providing medicine break up. They are giving in writing that
we will not provide, even though the cost of medicines are up to 60,000 how to deal with it ?
Resolution: TPAs need to insist on breakup for medicines. If any hospital denies, this may be
brought to the notice of Insurance Company.

222. Cataract Surgery PPN sublimit

In case cataract surgery the maximum sublimit is Rs24000/-. However the PPN cataract sublimit
is more than that. Which should we follow?
Resolution: The lower limit is applicable, in this case the policy sublimit of Rs 24000/-. 

223. When hospitals come for open billing for the PPN tariff
instead of single line billing. Can proportionate deductions be applied if the room rent exceeds
the eligibility?
Resolution: If the final hospital bill amount is equal to the eligible PPN package, no deductions
will be done. If the billed amount is higher than the agreed package without any justification,
then the eligible PPN package rate is to be paid. Wherever the hospital is charging extra from
the patient, such cases should be taken up the lead TPA and hospital.

224. Eligible PPN room categories

Scenario 1: The eligible room for the claimant falls in between two categories, the room rent
limit for the claimant is 3000, whereas the room rent category available in PPN hospital is 2500
and 4000. Which room category tariff is to be applied?
Resolution: If the procedure is included in the PPN package, then the eligible room category
the nearest room rent that is Rs 2500. Even in PPN hospitals, room rent cap and proportionate
deduction will apply for those surgical procedures not coming under package and medical
procedures. For those procedures which are under package, if the packages are for different
room variants such as general ward, twin sharing or single AC, please ascertain the room rent
which should be the nearest to the Sum Insured and pay as per this package. If the package is
only for single AC, then the package rates has to be paid.
Scenario 2: The eligible room for the claimant is not available in the PPN hospital .The room
rent limit is 1000 and the lowest room category in the hospital starts from 3500. Is the PPN
tariff eligible for this claimant? If not, should we ask for open billing and apply proportionate
deductions?

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Resolution: If the procedure is not included in PPN packages or if the eligibility of the PPN
package is linked to the room rent eligibility (as followed in some PPN cities such as Pune),
then the hospital SoC will be applicable, on which proportionate deductions are to be applied.
If the procedure is included in the PPN package, then we pay the eligible package for General
Ward.

225. In reimbursement claims, PPN hospital is charging more than

GIPSA PPN rates
If we deduct, the Ombudsman asks us to pay to the customer.  The policy wordings does not
contain the information about the GIPSA PPN Hospitals & their packages (Inclusion, Exclusion,
LOS etc). Hence quite difficult to convince insured in case of any deductions.
In case of reimbursement claims in Non PPN Hospital, we have to settle the claim for reasonable
amount which is same or more than PPN Hospital. Hence the purpose of implementation of PPN
i.e. Uniformity of SOC & Reduction in Claim Out go seems to be defeated. Hence the number of
hospitals on GIPSA PPN should be increased & also cashless should be made compulsory for
treatment in GIPSA PPN Hospital. 
There should be clear indications in Policy that Cashless and Reimbursement cases under PPN
procedure in Network hospital would attract same liability under the policy.
Resolution: Pay as a normal reimbursement case. But take up the matter with hospital and
lead PPN for each and every case. Lead TPA should note all such exceptions. If the cases are
persistent then the hospital should be removed from PPN.
This should be settled as normal case and in case where the room is exceeding the eligibility
limit, then proportionate deduction should be applied.

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Annexure I

Assistant
Sr Procedures not in PPN list but are being carried out frequently
Surgeon
No as per our data in hospitals PAN INDIA
required
1 Total Joint Replacement, any site Yes
2 Aorta, Descending Aortic Aneurysm, Excision and Insertion of Graft Yes
3 Aorta, Ruptured Abdominal Aortic Aneurysm, Excision and Yes
Insertion of Graft
4 Aorta, Thoraco-abdominal Aneurysm, Excision and Insertion of Graft Yes
5 Artery-Carotid, Arterio-Occlusive Lesions, External Carotid- Yes
Internal Carotid Bypass
6 Artery-Carotid, Atherosclerosis, Carotid Endarterectomy Yes
7 Artery-Carotid, Carotid Body Tumour, Excision Yes
8 Artery-Pulmonary, Pulmonary Embolism, Pulmonary Embolectomy Yes
using Cardiopulmonary Bypass
9 Bladder, Various Lesions, Total Cystectomy Yes
10 Blood Vessels, Defect, Major Grafts (multiple) Yes
11 Bone, Tumour (malignant), Wide/Major Resection and Yes
Reconstruction
12 Ca Tongue,Wide Excision with Buccal Mucosal Yes
grafting - Floor Of Mouth
13 Elbow, Various Lesions, Hemiarthroplasty Yes
14 Esophagus, Tumour, Allison/Ivor-Lewis Operation Yes
15 Esophagus, Tumour, Total Esophagectomy Yes
16 Esophagus, Varices, Esophageal/Transection with Splenectomy Yes
17 Head, Various Lesions, Craniofacial Resection and Reconstruction Yes
18 Head-Face, Tumor, Craniofacial Resection with Reconstruction Yes
19 Heart, Proximal Aortic Aneurysm, Aortic Root Replacement with Yes
Coronary Artery Reimplantation
20 Heart, Various Lesions, Heart Transplantation Yes
21 Heart, Ventricular Aneurysm, Resection Without Yes
Coronary Artery Bypass
22 Hip, Avascular Necrosis, Core Decompression with Grafting Yes
23 Liver, Trauma/Tumour, Liver Transplant Yes
24 Lung Transplant Or Combined Heart-Lung Transplant Yes
25 Major Burns > 50% Body Surface Involved Yes
26 Mandible (excluding alveolar margins), Various Lesions, Complex Yes
Osteotomy/Ostectomy

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Assistant
Sr Procedures not in PPN list but are being carried out frequently
Surgeon
No as per our data in hospitals PAN INDIA
required
27 Mandible and Maxilla, Various Lesions, Osteotomy including Yes
Segmental Osteotomy with/without Grafting
28 Mandible, Various Lesions, Mandibular Ramus/Body Ostectomy/ Yes
Osteotomy with Segmental Osteotomy
29 Mandible, Various Lesions, Segmental Resection with Bone Graft Yes
30 Maxilla (excluding alveolar margins) and/or Zygoma, Various Yes
Lesions, Complex Ostectomy/Osteotomy
31 Maxilla, Bilateral Complete Alveolar Cleft, Bone Graft and Closure of Yes
Naso Buccal Fistula
32 Maxilla, Lefort II Fracture, Osteotomy Yes
33 Maxilla, Lefort III Fracture, Osteotomy Yes
34 Maxilla, Various Lesions, Ostectomy/Osteotomy Yes
(more than one segment)
35 Mouth, Intra-Oral Tumour, Radical Excision With Resection Of Yes
Mandible And Lymph Nodes
36 Mouth, Malignant Tumor, Wide Excision and Major Reconstruction Yes
37 Mouth, Various Lesions, Pharyngotomy (lateral) with Excision of Yes
Tongue and Reconstruction
38 Other Intra-Cranial Operations Requiring Craniotomy Yes
39 Pancreatectomy Yes
40 Pharynx, Various Lesions, Pharyngotomy (lateral) with Excision of Yes
Tongue and Reconstruction
41 Radical Abdominal Hysterectomy Modified Radical Hysterectomy Yes
Wertheims Operation
42 Radical Dissection Of Thoracic Structures Block [En Bloc] Yes
Dissection Of Bronchus, Lobe Of Lung, Brachial Plexus, Intercostal
Structure, Ribs (Transverse Process), And Sympathetic Nerves
43 Radical Glossectomy Yes
44 Radical Neck Dissection Yes
45 Radical Prostatectomy Prostatovesiculectomy Radical Yes
Prostatectomy By Any Approach
46 Repair Of Cerebral, Spinal Arterio-Venous Malformations, Cerebral Yes
Aneurysms And Excision Of Cerebral Tumours
47 Ileocolectomy Right Radical Colectomy Yes
48 Skull, Craniostenosis (multiple sutures), Operation Yes
49 Skull, Craniostenosis (single sutures), Operation Yes
50 Spine (cervical), Various Lesions, Laminoplasty Yes

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Assistant
Sr Procedures not in PPN list but are being carried out frequently
Surgeon
No as per our data in hospitals PAN INDIA
required
51 Surgery To Remove Benign Cerebral Tumours And Space Occupying Yes
Lesions Via Craniotomy
52 Tonsils, Tumour, Resection with Reconstruction Yes
53 Thorax, Various Lesions Thoracotomy With Pulmonary Yes
Decortication
54 Bile Duct Various Lesions, Hepatico-Jejunostomy Yes
55 Artery (distal extremity/digit), Various Lesions, Microvascular Yes
Repair
56 Artery, Arterio-venous Fistula, Dissection and Repair with Yes
Restoration of Continuity
57 Artery, Trauma/Resection, Arterial Anastomosis Yes
58 Artery, Various Lesions, Axillary-femoral/Subclavian-femoral By- pass Yes
59 Arthrotomy Yes
60 Bile Duct, Various Lesions, Transduodenal Sphincteroplasty/ Yes
Sphincterotomy
61 Bronchus, Various Lesions, Bronchoplastic Procedure Yes
62 Diaphragm, Tumour, Excision Yes
63 Endolymphatic Sac, Various Lesions, Transmastoid Shunt Yes
Procedure
64 Esophagus, Tumour, Bypass with Stomach/Intestine Yes
65 Excision Of Bone Tumours Deep Yes
66 Foot, Various Lesions, Triple Arthrodesis Yes
67 Gastrectomy Yes
68 Heart, Coronary Disease, Coronary Arteriography (Selective) Yes
69 Heart, Pericardial Disease, Pericardiectomy Yes
70 Labyrinth, Various Lesions, Destruction/Labyrinthotomy No
71 Larynx, Larynogofissure, External Operation No
72 Mandible, Tumours, Marginal Resection with/without Bone Graft Yes
73 Mandible, Various Lesions, Complex Genioplasty (not as a Yes
combined procedure)
74 Mandible, Various Lesions, Coronoidectomy No
75 Mandible, Various Lesions, Insertion of Transmandibular Implant/ No
Subperiosteal Implant
76 Mandible, Various Lesions, Mandibular Ramus/Body Ostectomy/ No
Osteotomy without Segmental Osteotomy
77 Mandible, Various Lesions, Segmental Ostectomy/Osteotomy No
(one segment only)

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Assistant
Sr Procedures not in PPN list but are being carried out frequently
Surgeon
No as per our data in hospitals PAN INDIA
required
78 Mandible, Various Lesions, Simple Genioplasty No
(not as a combined procedure)
79 Maxilla, Deformity-Lefort I, Osteotomy Yes
80 Maxilla, Lefort I Fracture, Osteotomy Yes
81 Maxilla, Various Lesions, Resection/Hemimaxillectomy Yes
82 Maxilla, Various Lesions, Segmental Ostectomy/Osteotomy Yes
(one segment only)
83 Nail Bed, Deformity/Defect Reconstruction No
84 Open Reduction Of Dislocations Superficial/Major Joints Yes
85 Open Reduction Of Fracture Dislocation & Internal Fixation Yes
Of Spine/Pelvis
86 Operations For Brachial Plexus Yes
87 Pancreas, Tumour, Triple Bypass Yes
88 Parapharyngeal Space, Tumour, Excision Yes
89 Rectum, Various Lesions, Hartmann’s Procedure Yes
90 Retro-Peritoneum, Tumour, Removal Yes
91 Skull, Osteomyelitis, Craniectomy Yes
92 Spinal Cord, Intractable Pain, Percutaneous Cordotomy Yes
93 Splenectomy Yes
94 Tendon-Extensor (Upper Limb), Adhesion, Tenolysis (multiple) No
95 Tendon-Flexor (Upper Limb), Adhesion, Tenolysis (multiple) No
96 Tendon-Flexor (Upper Limb), Defect, Grafting (single) No
97 Thorax, Tumour (Mediastinal), Resection Yes
98 Valvuloplasty Yes
99 Vein-Portal, Portal Hypertension, Bypass Yes
100 Vulva, Malignant Condition, Vulvectomy (Simple) Yes
Without Use Of Laser
101 Rectum, Hirschsprung’S Disease, Recto Sigmoidectomy Yes

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Assistant surgeon
S.No Name of the PPN Procedure/Treatment
required
1 CABG Yes
2 Angiography(Day Care) No
3 Angiography With Angioplasty Yes
4 Valve Replacement* Yes
5 Temporary Pacemaker Implantation No
6 Permanent Pacemaker Implantation No
7 DVR- Double Valve Replacement (Cardiac Surgery) Yes
8 EPS and RFA No
9 Tonsillectomy No
10 Adenotonsillectomy No
11 Tympanoplasty No
12 Mastoidectomy No
13 Septoplasty No
14 Nasal Polyps/ Sinusitis (FESS)- Unilateral No
15 Nasal Polyps/ Sinusitis (FESS)- Bilateral No
16 Cortical Mastoidectomy With Myringoplasty No
17 Peritonsilar Abscess Drainage No
18 Septoplasty + Turbinoplasty / Conchaplasty No
19 Myringotomy With Grommet Insertion No
20 Meatotomy No
21 Haemorrhoidectomy No
22 Haemorrhoidectomy + Fissurectomy No
23 Fissure Dilatation No
24 Fissureectomy No
25 Fistula High End No
26 Fistula Low End No
27 Appendectomy (Lap)/ Open No. If any rupture
or abscess or
generalized
peritonitis, should
be allowed.
28 Cholesystectomy (Lap)/ Open Yes
29 Excision Of Pilonoidal Sinus With Flap Cover No
30 Excision Of Pilonoidal Sinus With Primary Closure No
31 Mastectomy (Simple) No
32 Mastectomy (Radical) Yes

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Assistant surgeon
S.No Name of the PPN Procedure/Treatment
required
33 Thyroidectomy (Total/Subtotal) Yes
34 Inguinal Herniorraphy- Unilateral No. If recurrent,
stragulation, should
be allowed
35 Inguinal Hernioplasty- Unilateral No. If recurrent,
stragulation, should
be allowed
36 Inguinal Herniorraphy- Bilateral No. If recurrent,
stragulation, should
be allowed
37 Inguinal Hernioplasty- Bilateral No. If recurrent,
stragulation, should
be allowed
38 Umblical Herniorraphy No. If recurrent,
stragulation, should
be allowed
39 Umblical Herniorraplasty No. If recurrent,
stragulation, should
be allowed
40 Incisional Herniorraphy No. If recurrent,
stragulation, should
be allowed
41 Incisional Hernioplasty No. If recurrent,
stragulation, should
be allowed
42 Circumcision No
43 Perianal Abcess No
44 Breast Lumpectomy No
45 AV Fistula No
46 Hydrocele No
47 URS(Therapeutic) No
48 Right Or Left Hemi Coloctomy Yes
49 Resection And Anastomosis Of Small Intestine Yes
50 ESWL(Extracorporeal Shock Wave Lithotripsy) No
51 Exploratory Laparotomy Yes
52 ERCP – EPT/Stenting/Stone Removal No
53 Renal Transplant Surgery ( Recipient) Yes

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Assistant surgeon
S.No Name of the PPN Procedure/Treatment
required
54 VP Shunting Yes
55 Normal Delivery No
56 LSCS (With Well Baby Care) Yes
57 Lap Hysterectomy (Abdominal/Vaginal)/TAH +BSO Yes
Adhesiolysis
58 Instrumental Delivery (Including Well Baby Care) No
59 Ovarian Cystectomy/ Myomectomy Yes
60 Dilatation & Curettage (D&C) No
61 Vaginal-Vault Prolapse Repair Yes
62 Laparoscopic Ovarian Drilling No
63 IMRT(Cancer Radiation Therapy) Intensity Modulated No
Radiation Therapy
64 VMAT(Cancer Radiation Therapy) Volumetric No
Modulated Arc Therapy
65 SBRT (Cancer Radiation Therapy) Stereotactic Body No
Radiation Therapy
66 SRS Brain (Cancer Radiation Therapy) Stereotactic Radio No
Surgery
67 SRT Brain (Cancer Radiation Therapy) Stereotactic No
Fractionated Radiation
68 3 D CRT (Cancer Radiation Therapy) 3d Conformal Radiation No
Therapy
69 IGRT (Cancer Radiation Therapy) Image Guided Radiation No
Therapy
70 Cataract + Cost Of Lens 7000/-( Including Lens) No
71 Retinal Detachment No
72 Vitrectomy No
73 Vitrectomy With Gas Temponade No
74 Vitrectomy With Silicon Temponade No
75 Vitrectomy - Membrane Peeling- Endolaser No
76 Vitrectomy Sutureless + Membranectomy + Endolaser No
77 Vitrectomy - Membrane Peeling - Endolaser - Silicon Oil Or No
Gas - With Or Without Belt Buckling
78 Total Knee Replacement (Unilateral) Yes
79 Total Knee Replacement (Bilateral) Yes
80 Hip Replacement (Unilateral) Yes

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Assistant surgeon
S.No Name of the PPN Procedure/Treatment
required
81 Hip Replacement (Bilateral) Yes
82 Fracture Neck Femur (Bipolar Arthroplasty/Multiple Screw Yes
Fixation
83 Femur Shaft Fracture - Proximal / Middle / Distal - Yes
(Excluding Implant)
84 Tibia Fracture Proximal / Middle / Distal - ORIF / CRIF With Yes
Nailing / Lock
85 Ankle / Tibia Fracture - ORIF / CRIF With Screws / TBW- Yes
(Excluding Implant)
86 Arthrodesis - Wrist / Ankle / Subtalar - (Excluding Implant) Yes
87 Foot Fractures - With Wires No
88 Foot Fractures - With Screws No
89 Calcaneal Fracture : With Plates No
90 Shoulder / Humerous / Elbow / Both Bones Forearm Yes
Fractures - Plates Ana
91 Single Forearm Fracture / Wrist Fracture - With Plate Yes
(Excluding Implants)
92 Scaphoid Fracture Fixation Yes
93 Hand -’K’ Wires - Single Fracture No
94 Hand -’K’ Wires - Multiple Fracture No
95 Therapeutic Arthroscopy No
96 Arthroscopic Surgery ( Other Than ACL) / Menisectomy No
97 Shoulder - Arthroscopy / Open - Bankart Yes
98 Shoulder - Arthroscopy / Open - Laterjet / Bone Block Yes
99 Shoulder - Arthroscopy / Open - Cuff Repair Yes
100 Shoulder - Arthroscopy / Open - Cuff Repair With Anchors Yes
101 Shoulder - Arthroscopy / Open - Sub Acromial No
Decompression
102 ACL+PCL - Reconstruction (Exclude Implant) Yes.
103 Laminectomy/Discectomy Yes
104 Stabilization of Spinal Column Yes
105 Thoraco / Lumbar Global Fixation+ / Bone Graft (Excluding Yes
Implants)
106 Thoraco / Lumbar - Anterior Interbody Fixation + /-Bone Yes
Grafting (Excluding Implants)
107 Carpel Tunnel Release No

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Assistant surgeon
S.No Name of the PPN Procedure/Treatment
required
108 Carpel Tunnel Release - Bilateral No
109 Close Reduction Of Fracture Of Limbs And Pop No
110 Reduction Of Compound Fractures Yes
111 Close Reduction Of Dislocations Yes
112 Implant Removal (Femur / Tibia) No
113 Bone Grafting For Non Unions - Lower Limb Yes
114 Bone Grafting For Non Unions - Upper Limbs Yes
115 Acetabular Fracture - Posterior Wall / Column ORIF Yes
(Including Implant)
116 Acetabular Fracture - Posterior Wall / Column ORIF Yes
(Including Implant)
117 Pelvis Fracture - External Fixation (Including Implant) Yes
118 MCL Reconstruction/Repair Yes
119 Reduction Of Dislocation In GA No
120 DJ Stent Removal No
121 PCNL- Unilateral Yes
122 PCNL - Bi Lateral Yes
123 TURP/Laser Holmium No. But allowed in
radical prostectomy
124 Dialysis No
125 Cystoscopy(Therapeutic) No
126 Cystoscopy URS With DJ Stending (Unilateral) No
127 Nephrectomy/Nephrolithomy/Pyelolithotomy Yes
128 Orchidectomy Yes
129 Varicose Veins(Surgical As Well As Laser) No

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Annexure II
Sr No Congenital Internal Sr No Congenital Internal
1 Absence and agenesis of lacrimal 30 Atrioventricular septal defect
apparatus 31 Bicornate uterus
2 Absence of eustachian tube 32 branchial cleft malformations
3 Absence of iris 33 Cervical rib
4 Accessory kidney 34 Choanal atresia
5 Accessory lobe of lung 35 Choledochal cyst
6 Agenesis and aplasia of cervix 36 Chondrodysplasia punctata
7 Agenesis and aplasia of uterus 37 Chondroectodermal dysplasia
8 Agenesis aplasia and hypoplasia of 38 Coarctation of aorta
gallbladder
39 Coloboma of iris
9 Agenesis aplasia and hypoplasia of
pancreas 40 Coloboma of lens
10 Agenesis of lung 41 Common arterial trunk
11 Agenesis of ureter 42 Congenital absence and hypoplasia
of umbilical artery
12 Annular pancreas
43 Congenital absence and
13 Anomalous portal venous malformations of spleen
connection
44 Congenital absence atresia and
14 Anomalous pulmonary venous stenosis of duodenum
connection
45 Congenital absence atresia and
15 Anomaly of pleura stenosis of ileum
16 Aortopulmonary septal defect 46 Congenital absence atresia and
17 Arhinencephaly stenosis of jejunum
18 Arnold-Chiari syndrome 47 Congenital absence atresia and
19 Arteriovenous malformation stenosis of large intestine part
(peripheral) 48 Congenital absence atresia and
20 Arteriovenous malformation of stenosis of parts of large intestine
cerebral vessels 49 Congenital absence atresia and
21 Arteriovenous malformation of stenosis of parts of small intestine
precerebral vessels 50 Congenital absence atresia and
22 Atresia of aorta stenosis of rectum with fistula
23 Atresia of bile ducts 51 Congenital absence atresia and
stenosis of rectum without fistula
24 Atresia of esophagus with
tracheo-esophageal fistula 52 Congenital absence atresia and
stenosis of small intestine part
25 Atresia of esophagus without
fistula 53 Congenital absence of bladder
and urethra
26 Atresia of foramina of Magendie
and Luschka 54 Congenital absence of ovary
27 Atresia of pulmonary artery 55 Congenital absence of vagina
28 Atresia of vas deferens 56 Congenital aphakia
29 Atrial septal defect 57 Congenital bronchiectasis

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Sr No Congenital Internal Sr No Congenital Internal

58 Congenital bronchomalacia 88 Congenital malformation of kidney
59 Congenital cauda equina 89 Congenital malformation of knee
malformations
90 Congenital malformation of larynx
60 Congenital cerebral cysts
91 Congenital malformation of lung
61 Congenital cyst of mediastinum
92 Congenital malformation of
62 Congenital cystic lung peripheral vascular system
63 Congenital deformity of spine 93 Congenital malformation of
64 Congenital diaphragmatic hernia respiratory system
65 Congenital dilatation of esophagus 94 Congenital malformation of stomach
66 Congenital displaced lens 95 Congenital malformation of
tricuspid valve
67 Congenital diverticulum of bladder
96 Congenital malformation of upper
68 Congenital diverticulum of alimentary tract
esophagus
97 Congenital malformation of
69 Congenital fistulae between uterus urinary system
and digestive and urinary tracts
98 Congenital malformation of uterus
70 Congenital glaucoma and cervix
71 Congenital heart block 99 Congenital malformations of
72 Congenital hiatus hernia adrenal gland
73 Congenital hydronephrosis 100 Congenital malformations of aorta
74 Congenital hypertrophic pyloric 101 Congenital malformations of aortic
stenosis and mitral valves
75 Congenital hypoplasia and 102 Congenital malformations of bile
dysplasia of lung ducts
76 Congenital insufficiency of aortic 103 congenital malformations of
valve bronchus
77 Congenital laryngeal stridor 104 Congenital malformations of
78 Congenital laryngomalacia corpus callosum
79 congenital lens malformations 105 Congenital malformations of
endocrine glands
80 Congenital malformation of bony
thorax 106 Congenital malformations of
fallopian tube and broad ligament
81 Congenital malformation of
circulatory system 107 Congenital malformations of
gallbladder
82 Congenital malformation of
digestive system 108 Congenital malformations of great
veins
83 Congenital malformation of ear
ossicles 109 Congenital malformations of
intestinal fixation
84 Congenital malformation of
esophagus 110 congenital malformations of liver
85 Congenital malformation of heart 111 Congenital malformations of
middle ear
86 Congenital malformation of inner
ear 112 Congenital malformations of ovary
87 Congenital malformation of 113 Congenital malformations of
intestine pharynx

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Sr No Congenital Internal Sr No Congenital Internal

114 congenital malformations of renal 143 Congenital unstable hip
artery 144 Congenital vesico-uretero-renal
115 Congenital malformations of reflux
salivary glands and ducts 145 Cystic disease of liver
116 congenital malformations of 146 Developmental ovarian cyst
trachea
147 Dextrocardia
117 congenital malformations of
vagina 148 Diastematomyelia
118 congenital malformations of vas 149 Diastrophic dysplasia
deferens epididymis seminal 150 Discoid meniscus
vesicles and prostate
151 Discordant atrioventricular
119 Congenital megaureter connection
120 Congenital mitral insufficiency 152 Double inlet ventricle
121 Congenital mitral stenosis 153 Double outlet left ventricle
122 Congenital occlusion of ureter 154 Double outlet right ventricle
123 Congenital pancreatic cyst 155 Doubling of uterus
124 Congenital pharyngeal pouch 156 Doubling of uterus with doubling
125 Congenital posterior urethral of cervix and vagina
valves 157 Doubling of vagina
126 Congenital pulmonary valve 158 Duplication of intestine
insufficiency
159 Duplication of ureter
127 Congenital pulmonary valve
stenosis 160 Ebstein’s anomaly
128 Congenital rectovaginal fistula 161 Ectopic kidney
129 Congenital renal artery stenosis 162 Ectopic testis
130 Congenital renal cyst 163 Ectopic tissue in lung
131 Congenital spondylolisthesis 164 Embryonic cyst of broad ligament
132 Congenital stenosis and stricture 165 Embryonic cyst of cervix
of bile ducts 166 Embryonic cyst of fallopian tube
133 Congenital stenosis and stricture 167 Enchondromatosis
of esophagus
168 Esophageal web
134 Congenital stenosis and stricture
of lacrimal duct 169 Fetal hydantoin syndrome
135 Congenital stenosis of aortic valve 170 Hirschsprung’s disease
136 Congenital stenosis of bronchus 171 Holoprosencephaly
137 Congenital subaortic stenosis 172 Hydromyelia
138 Congenital subglottic stenosis 173 Hyperplastic and giant kidney
139 Congenital torsion of ovary 174 Hypoplasia and dysplasia of spinal
cord
140 Congenital tracheo-esophageal
fistula without atresia 175 Hypoplastic left heart syndrome
141 Congenital tracheomalacia 176 Hypoplastic right heart syndrome
142 Congenital tricuspid stenosis 177 Imperforate Hymen

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Sr No Congenital Internal Sr No Congenital Internal

178 Imperforate hymen 210 Short rib syndrome
179 Laryngeal hypoplasia 211 Sinus fistula and cyst of branchial
cleft
180 Laryngocele
212 Situs inversus
181 Levocardia
213 Spherophakia
182 Longitudinal reduction defect of
femur 214 Spondyloepiphyseal dysplasia
183 Longitudinal reduction defect of 215 Stenosis of pulmonary artery
fibula 216 Supravalvular aortic stenosis
184 Longitudinal reduction defect of 217 Tetralogy of Fallot
radius
218 Total anomalous pulmonary
185 Longitudinal reduction defect of venous connection
tibia
219 Unicornate uterus
186 Longitudinal reduction defect of
ulna 220 Ventricular septal defect
187 Malformation of coronary vessels 221 Web of larynx
188 Malformation of urachus
189 Malformations of aqueduct of
Sylvius
190 Malformations of cerebral vessels
191 malformations of precerebral
vessels
192 Malposition of ureter
193 Mastocytosis
194 Meckel’s diverticulum (displaced)
(hypertrophic)
195 Medullary cystic kidney
196 Megalencephaly
197 Metaphyseal dysplasia
198 Osteopetrosis
199 Partial anomalous pulmonary
venous connection
200 Patent ductus arteriosus
201 Persistent cloaca
202 Persistent left superior vena cava
203 Portal vein-hepatic artery fistula
204 Potter’s syndrome
205 Progressive diaphyseal dysplasia
206 Pulmonary infundibular stenosis
207 Pulmonary valve atresia
208 Renal dysplasia
209 Sequestration of lung

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Annexure III

Sr No Congenital External Sr No Congenital External

1 Cleft Lip & Palate 38 Macrostomia
2 Club foot[CTEV] 39 Microstomia
3 Spina Bifida 40 Macrocheilia
4 Congenital Umbilical Hernia 41 Microcheilia
5 Ankyloglossia[Tongue Tie] 42 Congenital phlebectasia
6 Imperforate Anus 43 Agenesis and underdevelopment
7 Hypospadiasis of nose
8 Undescended Testes 44 Fissured notched and cleft nose
9 Anencephaly 45 Congenital perforated nasal septum
10 Craniorachischisis 46 Congenital malformation of nose
11 Frontal encephalocele 47 (Cleft hard palate bilateral)
12 Nasofrontal encephalocele 48 Cleft hard palate
13 Occipital encephalocele 49 (Cleft soft palate bilateral)
14 Microcephaly 50 Cleft soft palate
15 Congenital hydrocephalus 51 (Cleft hard palate with cleft soft
16 Septo-optic dysplasia of brain palate bilateral)
17 Amyelia 52 Cleft palate medial
18 Congenital ptosis 53 Cleft uvula
19 Congenital ectropion 54 Cleft palate
20 Congenital entropion 55 Cleft lip bilateral
21 Congenital malformation of orbit 56 Cleft lip median
22 Anophthalmos 57 Cleft lip unilateral
23 Microphthalmos 58 Cleft hard palate with bilateral
cleft lip
24 Macrophthalmos
59 Cleft hard palate with unilateral
25 Congenital cataract cleft lip
26 Congenital corneal opacity 60 Cleft soft palate with bilateral
27 Blue sclera cleft lip
28 Congenital absence of (ear) auricle 61 Cleft soft palate with unilateral
29 Congenital absence atresia and cleft lip
stricture of auditory canal (external) 62 Cleft hard and soft palate with
30 Accessory auricle bilateral cleft lip
31 Macrotia 63 Cleft hard and soft palate with
32 Microtia unilateral cleft lip
33 misshapen ear 64 Ankyloglossia
34 Misplaced ear 65 Macroglossia
35 Prominent ear 66 Congenital malformations of tongue
36 Preauricular sinus and cyst 67 congenital malformations of mouth
37 Webbing of neck 68 Congenital absence atresia and
stenosis of anus with fistula

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Sr No Congenital External Sr No Congenital External

69 Congenital absence atresia and 104 Congenital pes cavus
stenosis of anus without fistula 105 Congenital deformity of feet
70 Ectopic anus 106 Congenital facial asymmetry
71 Congenital fistula of rectum and anus 107 Congenital compression facies
72 Fusion of labia 108 Dolichocephaly
73 Congenital malformation of clitoris 109 Plagiocephaly
74 Congenital malformations of vulva 110 Pectus excavatum
75 Undescended testicle unilateral 111 Pectus carinatum
76 Undescended testicle bilateral 112 Congenital deformity of
77 Hypospadias balanic sternocleidomastoid muscle
78 Hypospadias penile 113 Congenital deformity of finger(s)
79 Hypospadias penoscrotal and hand
80 Hypospadias perineal 114 Congenital deformity of knee
81 Congenital chordee 115 Congenital bowing of femur
82 Hypospadias 116 Congenital bowing of tibia and fibula
83 Absence and aplasia of testis 117 Congenital bowing of long bones
84 Hypoplasia of testis and scrotum of leg
85 Congenital absence and aplasia of penis 118 Accessory finger(s)
86 Congenital vasocutaneous fistula 119 Accessory thumb(s)
87 Congenital malformation of male 120 Accessory toe(s)
genital organ 121 Polydactyly
88 Epispadias 122 Fused fingers
89 Exstrophy of urinary bladder 123 Webbed fingers
90 Congenital dislocation of hip 124 Fused toes
unilateral 125 Webbed toes
91 Congenital dislocation of hip 126 Polysyndactyly
bilateral 127 Syndactyly
92 Congenital dislocation of hip 128 Congenital complete absence of
93 Congenital partial dislocation of hip upper limb
unilateral 129 Congenital absence of upper arm
94 Congenital partial dislocation and forearm with hand present
of hip bilateral 130 Congenital absence of both forearm
95 Congenital partial dislocation of hip and hand
96 Congenital deformity of hip 131 Congenital absence of hand and
97 Congenital talipes equinovarus finger
98 Congenital talipes calcaneovarus 132 Lobster-claw hand
99 Congenital metatarsus (primus) 133 Congenital complete absence of
varus lower limb
100 congenital varus deformities of feet 134 Congenital absence of thigh and
101 Congenital talipes calcaneovalgus lower leg with foot present
102 Congenital pes planus 135 Congenital absence of both lower
leg and foot
103 congenital valgus deformities of feet

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Sr No Congenital External Sr No Congenital External

136 Congenital absence of foot and toe(s) 169 Ichthyosis vulgaris
137 Split foot 170 X-linked ichthyosis
138 Congenital absence of limb(s) 171 Lamellar ichthyosis
139 Phocomelia limb(s) 172 Congenital bullous ichthyosiform
140 Congenital malformations of upper erythroderma
limb(s) including shoulder girdle 173 Harlequin fetus
141 congenital malformations of lower 174 Congenital ichthyosis
limb(s) including pelvic girdle 175 Epidermolysis bullosa simplex
142 Arthrogryposis multiplex congenita 176 Epidermolysis bullosa letalis
143 Congenital malformation of limb(s) 177 Epidermolysis bullosa dystrophica
144 Craniosynostosis 178 Xeroderma pigmentosum
145 Craniofacial dysostosis 179 Incontinentia pigmenti
146 Hypertelorism 180 Ectodermal dysplasia (anhidrotic)
147 Macrocephaly 181 Congenital non-neoplastic nevus
148 Mandibulofacial dysostosis 182 Congenital absence of breast with
149 Oculomandibular dysostosis absent nipple
150 Congenital malformation of skull 183 Accessory breast
and face bones 184 Absent nipple
151 Spina bifida occulta 185 Accessory nipple
152 Klippel-Feil syndrome 186 Congenital malformation of breast
153 Congenital scoliosis due to 187 Congenital alopecia
congenital bony malformation 188 Anonychia
154 Congenital malformations of spine 189 Congenital leukonychia
not associated with scoliosis
190 Enlarged and hypertrophic nails
155 congenital malformations of ribs
191 congenital malformations of nails
156 Congenital malformation of
sternum 192 Neurofibromatosis (nonmalignant)
157 Achondrogenesis 193 Tuberous sclerosis
158 Thanatophoric short stature 194 Phakomatosis
159 Achondroplasia 195 Congenital malformation
syndromes predominantly affecting
160 Osteochondrodysplasia with defects facial appearance
of growth of tubular bones and
spine 196 Congenital malformation
syndromes predominantly
161 Osteogenesis imperfecta associated with short stature
162 Polyostotic fibrous dysplasia 197 Congenital malformation syndromes
163 Multiple congenital exostoses predominantly involving limbs
164 Exomphalos 198 Congenital malformation
165 Gastroschisis syndromes involving early
166 Prune belly syndrome overgrowth
167 Congenital malformations of 199 Marfan’s syndrome
abdominal wall 200 Conjoined twins
168 Ehlers-Danlos syndrome 201 Supravalvular aortic stenosis

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Annexure IV

Sl. No GENETIC DISORDERS ICD 10 Codes

1 18p Deletion Syndrome NA
2 1p36 Deletion Syndrome NA
3 21-Hydroxylase Deficiency E 25.0
4 45,X - See Turner Syndrome Q 96
5 46 XX True Hermaphrodite
6 47,XX,+21 - See Down Syndrome Q 90
7 47,XXX - See Triple X Syndrome Q 97.0
8 47,XXY - See Klinefelter’s Syndrome Q 98.0
9 47,XY,+21 - See Down Syndrome Q 90
10 47,XYY Syndrome Q 98.0
11 5-ALA Dehydratase-Deficient Porphyria - See ALA Dehydratase
NA
Deficiency
12 5-Aminolaevulinic Dehydratase Deficiency Porphyria - See ALA
NA
Dehydratase Deficiency
13 5p Deletion Syndrome - See Cri Du Chat Q 93.4
14 5p- Syndrome - See Cri Du Chat Q 93.4
15 AAT See Alpha 1-Antitrypsin Deficiency E 88.0
16 Absence Of Vas Deferens - See Congenital Absence Of The
Q 55.4
Vas Deferens
17 Absent Vasa - See Congenital Absence Of The Vas Deferens Q 55.4
18 Aceruloplasminemia E 83.1
19 ACG2 - See Achondrogenesis Type II Q 77.0
20 ACH - See Achondroplasia Q 77.4
21 Achondrogenesis Type II Q 77.0
22 Achondroplasia (Dwarfism) Q 77.4
23 Acid Beta-Glucosidase Deficiency - See Gaucher
E 75.2
Disease Type 1
24 Acrocephalosyndactyly (Apert) - See Apert Syndrome Q 87.7
25 Acrocephalosyndactyly, Type V - See Pfeiffer Syndrome Q 87.7
26 Acrocephaly - See Apert Syndrome Q 75.0
27 Acute Cerebral Gaucher’s Disease - See Gaucher
E 75.2
Disease Type 2
28 Acute Intermittent Porphyria E 80.2
29 ACY2 Deficiency - See Canavan Disease E 75.2
30 AD - See Alzheimer’s Disease G 30
31 Adelaide-Type Craniosynostosis - See Muenke Syndrome Q 75.0
32 Adenylosuccinate Lyase Deficiency NA

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Sl. No GENETIC DISORDERS ICD 10 Codes

33 ADP - See ALA Dehydratase Deficiency NA
34 Adrenal Gland Disorders - See 21-Hydroxylase Deficiency E 25.0
35 Adrenogenital Syndrome - See 21-Hydroxylase Deficiency E 25.0
36 Adrenoleukodystrophy E 71.3
37 Agammaglobulinaemia
38 AIP - See Acute Intermittent Porphyria E 80.2
39 AIS - See Androgen Insensitivity Syndrome E 34.5
40 AKU - See Alkaptonuria E 70.2
41 ALA Dehydratase Deficiency NA
42 ALA Dehydratase Porphyria - See ALA Dehydratase Deficiency NA
43 ALA-D Porphyria - See ALA Dehydratase Deficiency NA
44 Alcaptonuria E 70.2
45 Alexander Disease ICD 9: 331.89
46 Alkaptonuria - Alkaptonuric Ochronosis E 70.2
47 Alpha 1-Antitrypsin Deficiency E 88.0
48 Alpha-1 Proteinase Inhibitor E 88.0
49 Alpha-1 Related Emphysema E 88.0
50 Alpha-Galactosidase A Deficiency - See Fabry Disease E 75.2
51 ALS - See Amyotrophic Lateral Sclerosis G 12.2
52 Alström Syndrome NA
53 Alveolar Capillary Dysplasia
54 ALX - See Alexander Disease ICD 9: 331.89
55 Alzheimer’s Disease G 30
56 Amelogenesis Imperfecta K 005
57 Amino Levulinic Acid Dehydratase Deficiency - See ALA
NA
Dehydratase Deficiency
58 Aminoacylase 2 Deficiency - See Canavan Disease E 75.2
59 Amyotrophic Lateral Sclerosis G 12.2
60 Anderson-Fabry Disease - See Fabry Disease E 75.2
61 Androgen Insensitivity Syndrome E 34.5
62 Anemia D 64
63 Anemia, Hereditary Sideroblastic - See X-Linked Sideroblastic
D 64.0
Anemia
64 Anemia, Sex-Linked Hypochromic Sideroblastic - See X-Linked
D 64.0
Sideroblastic Anemia
65 Anemia, Splenic, Familial - See Gaucher Disease E 75.2
66 Angelman Syndrome Q 87.8
67 Angiokeratoma Corporis Diffusum - See Fabry Disease E 75.2
68 Angiokeratoma Diffuse - See Fabry Disease E 75.2

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Sl. No GENETIC DISORDERS ICD 10 Codes

69 Angiomatosis Retinae - See Von Hippel – Lindau Disease Q 85.8
70 ANH1 - See X-Linked Sideroblastic Anemia D 64.0
71 Ankylosing Spondylitis
72 APC Resistance, Leiden Type - See Factor V Leiden Thrombophilia ICD 9: 289.81
73 Apert Syndrome Q 87.8
74 AR Deficiency - See Androgen Insensitivity Syndrome E 34.5
75 Arachnodactyly - See Marfan Syndrome Q 87.4
76 AR-CMT2 - See Charcot-Marie-Tooth Disease, Type 2 G 60.0
77 Arnold -Chiari Malformation
78 ARNSHL - See Nonsyndromic Deafness#Autosomal Recessive NA
79 Arthrochalasis Multiplex Congenita - See Ehlers-Danlos
Q 79.6
Syndrome#Arthrochalasia Type
80 Arthro-Ophthalmopathy, Hereditary Progressive - See Stickler
Q 87.8
Syndrome#COL2A1
81 AS - See Angelman Syndrome Q 87.8
82 Asp Deficiency - See Canavan Disease E 75.2
83 Aspa Deficiency - See Canavan Disease E 75.2
84 Aspartoacylase Deficiency - See Canavan Disease E 75.2
85 Astrocytoma
86 A-T - See Ataxia Telangiectasia G 11.3
87 Ataxia Telangiectasia G 11.3
88 Autism ( =Autism Spectrum Disorder)
89 Autism-Dementia-Ataxia-Loss Of Purposeful Hand Use Syndrome
F 84.2
- See Rett Syndrome
90 Autoimmune Lymphoproliferative Syndrome
91 Autoimmune Polyendocrine Syndrome
92 Autosomal Dominant Juvenile ALS - See Amyotrophic Lateral
G 12.2
Sclerosis, Type 4
93 Autosomal Dominant Opitz G/BBB Syndrome - See 22q11.2
D 82.1
Deletion Syndrome
94 Autosomal Recessive Form Of Juvenile ALS Type 3 -
G 12.2
See Amyotrophic Lateral Sclerosis#Type 2
95 Autosomal Recessive Nonsyndromic Hearing Loss -
NA
See Nonsyndromic Deafness#Autosomal Recessive
96 Autosomal Recessive Sensorineural Hearing Impairment And
NA
Goiter - See Pendred Syndrome
97 Axd - See Alexander Disease ICD 9: 331.89
98 Ayerza Syndrome - See Primary Pulmonary Hypertension I 27.0
99 B Variant Of The Hexosaminidase GM2 Gangliosidosis -
E 75.0
See Sandhoff Disease

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Sl. No GENETIC DISORDERS ICD 10 Codes

100 BANF - See Neurofibromatosis Type II Q 85.0
101 Barrett’s Syndrome / Barterr
102 Beare-Stevenson Cutis Gyrata Syndrome NA
103 Benign Paroxysmal Peritonitis - See Mediterranean Fever, Familial E 85.0
104 Benjamin Syndrome NA
105 Beta-Thalassemia D 56.1
106 BH4 Deficiency - See Tetrahydrobiopterin Deficiency E 70.1
107 Bilateral Acoustic Neurofibromatosis - See Neurofibromatosis
Q 85.0
Type II
108 Biotinidase Deficiency ICD 9: 277.6
109 Birt–Hogg–Dubé Syndrome NA
110 Bleeding Disorders - See Factor V Leiden Thrombophilia ICD 9: 289.81
111 Blighted Ovum
112 Bloch-Sulzberger Syndrome - See Incontinentia Pigmenti Q 82.3
113 Bloom Syndrome ICD 9: 757.39
114 Bone Marrow Diseases - See X-Linked Sideroblastic Anemia D 64.0
115 Bonnevie-Ullrich Syndrome - See Turner Syndrome Q 96
116 Bourneville Disease - See Tuberous Sclerosis Q 85.1
117 Bourneville Phakomatosis - See Tuberous Sclerosis Q 85.1
118 Bowen-Conradi Syndrome
119 Bowen’s Disease
120 Brain Diseases - See Prion Disease A 81
121 Brittle Bone Disease - See Osteogenesis Imperfecta Q 78.0
122 Broad Thumb-Hallux Syndrome - See Rubinstein-Taybi Syndrome Q 87.2
123 Bronze Diabetes - See Hemochromatosis R 79.0
124 Bronzed Cirrhosis - See Hemochromatosis R 79.0
125 Brugada Syndrome
126 Bulbospinal Muscular Atrophy, X-Linked - See Kennedy’s Disease G 12.1
127 Burger-Grutz Syndrome - See Lipoprotein Lipase Deficiency,
NA
Familial
128 CADASIL Syndrome NA
129 Campomelic Dysplasia NA
130 Canavan Disease E 75.2
131 Carboxylase Deficiency, Multiple, Late-Onset -See Biotinidase
ICD 9: 277.6
Deficiency
132 Cardiomyopathy -See Noonan Syndrome Q 87.1
133 Carnitine Pamitoyl Transferase Deficiency
134 Cat Cry Syndrome -See Cri Du Chat Q 93.4
135 CAVD -See Congenital Absence Of The Vas Deferens Q 55.4

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Sl. No GENETIC DISORDERS ICD 10 Codes

136 Caylor Cardiofacial Syndrome - See 22q11.2 Deletion Syndrome D 82.1
137 CBAVD - See Congenital Absence Of The Vas Deferens Q 55.4
138 Celiac Disease K 90.0
139 CEP - See Congenital Erythropoietic Porphyria E 80.0
140 Ceramide Trihexosidase Deficiency - See Fabry Disease E 75.2
141 Cerebelloretinal Angiomatosis, Familial - See Von Hippel-Lindau
Q 85.8
Disease
142 Cerebral Gigantism
143 Cerebral Arteriopathy NA
144 Cerebral Autosomal Dominant Ateriopathy NA
145 Cerebral Sclerosis - See Tuberous Sclerosis Q 85.1
146 Cerebroatrophic Hyperammonemia - See Rett Syndrome F 84.2
147 Cerebroside Lipidosis Syndrome - See Gaucher Disease E 75.2
148 CF - See Cystic Fibrosis  E 84
149 CGD Chronic Granulomatous Disorder D 71
150 CH - See Congenital Hypothyroidism E 00
151 Charcot Disease - See Amyotrophic Lateral Sclerosis G 60.0
152 Charcot-Marie-Tooth Disease G 60.0
153 Chondrodystrophia - See Achondroplasia Q 77.4
154 Chondrodystrophy Syndrome - See Achondroplasia Q 77.4
155 Chondrodystrophy With Sensorineural Deafness -
NA
See Otospondylomegaepiphyseal Dysplasia
156 Chondrogenesis Imperfecta - See Achondrogenesis, Type II Q 77.0
157 Choreoathetosis Self-Mutilation Hyperuricemia Syndrome -
E 79.1
See Lesch-Nyhan Syndrome
158 Choroideremia
159 Chronic Recurrent Multifocal Osteomyelitis
160 Classic Galactosemia - See Galactosemia E 74.2
161 Classical Ehlers-Danlos Syndrome - See Ehlers-Danlos
Q 79.6
Syndrome#Classical Type
162 Classical Phenylketonuria - See Phenylketonuria E 70.0
163 Cleft Lip And Palate - See Stickler Syndrome Q 87.8
164 Cloverleaf Skull With Thanatophoric Dwarfism -
Q 77.1
See Thanatophoric Dysplasia#Type 2
165 CLS - See Coffin-Lowry Syndrome ICD 9: 759.89
166 Clubfoot
167 CMT - See Charcot-Marie-Tooth Disease G 60.0
168 Cockayne Syndrome Q 87.1
169 Coffin-Lowry Syndrome ICD 9: 759.89

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170 Collagenopathy, Types II And XI NA
171 Colour Blindness
172 Complete HPRT Deficiency - See Lesch-Nyhan Syndrome E 79.1
173 Complete Hypoxanthine-Guanine Phosphoribosyltransferase
E 79.1
Deficiency - See Lesch-Nyhan Syndrome
174 Compression Neuropathy - See Hereditary Neuropathy With
ICD 9: 355.9
Liability To Pressure Palsies
175 Congenital Adrenal Hyperplasia - See 21-Hydroxylase Deficiency E 25.0
176 Congenital Bilateral Absence Of Vas Deferens - See Congenital
Q 55.4
Absence Of The Vas Deferens
177 Congenital Dyserythropoieotic Anemia
178 Congenital Erythropoietic Porphyria E 80.0
179 Congenital Heart Disease Q 20 - Q26
180 Congenital Hypomyelination - See Charcot-Marie-Tooth
G 60.0
Disease#Type 1 & #Type 4
181 Congenital Hypothyroidism E 00
182 Congenital Methemoglobinemia -
D 74
See Methemoglobinemia#Congenital Methaemoglobinaemia
183 Congenital Osteosclerosis - See Achondroplasia Q 77.4
184 Congenital Sideroblastic Anaemia - See X-Linked Sideroblastic
D 64.0
Anemia
185 Connective Tissue Disease NA
186 Conotruncal Anomaly Face Syndrome - See 22q11.2 Deletion
D 82.1
Syndrome
187 Cooley’s Anemia - See Beta-Thalassemia D 56.1
188 Copper Storage Disease - See Wilson’s Disease E 83.0
189 Copper Transport Disease - See Menkes Disease E 83.0
190 Coproporphyria, Hereditary - See Hereditary Coproporphyria E 80.2
191 Coproporphyrinogen Oxidase Deficiency - See Hereditary
E 80.2
Coproporphyria
192 Cowden Syndrome ICD 9: 759.6
193 CPO Deficiency - See Hereditary Coproporphyria E 80.2
194 CPRO Deficiency - See Hereditary Coproporphyria E 80.2
195 CPX Deficiency - See Hereditary Coproporphyria E 80.2
196 Craniofacial Dysarthrosis - See Crouzon Syndrome Q 75.1
197 Craniofacial Dysostosis - See Crouzon Syndrome Q 75.1
198 Cretinism - See Congenital Hypothyroidism E 00
199 Creutzfeldt-Jakob Disease - See Prion Disease A 81.0
200 Cri Du Chat Q 93.4
201 Crohn’s Disease, Fibrostenosing K 50

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202 Crouzon Syndrome Q 75.1
203 Crouzon Syndrome With Acanthosis Nigricans -
NA
See Crouzonodermoskeletal Syndrome
204 Crouzonodermoskeletal Syndrome NA
205 CS - See Cockayne Syndrome (Q 87.1); See Cowden Syndrome
Q 87.1
(ICD 9: 759.6)
206 Curschmann-Batten-Steinert Syndrome - See Myotonic Dystrophy G 71.1
207 Cutis Gyrata Syndrome Of Beare-Stevenson - See Beare-Stevenson
NA
Cutis Gyrata Syndrome
208 Cystic Fibrosis
209 Dappled Metaphysis Syndrome - See Spondyloepimetaphyseal
NA
Dysplasia, Strudwick Type
210 DAT - Dementia Alzheimer’s Type - See Alzheimer’s Disease F 02.1
211 DBMD - See Muscular Dystrophy, Duchenne And Becker Types G 71.0
212 De Grouchy Syndrome 1 - See De Grouchy Syndrome NA
213 Deafness With Goiter - See Pendred Syndrome NA
214 Deafness-Retinitis Pigmentosa Syndrome - See Usher Syndrome NA
215 Deficiency Disease, Phenylalanine Hydroxylase -
E 70.0
See Phenylketonuria
216 Degenerative Nerve Diseases G 30 - G 32
217 Dejerine-Sottas Syndrome - See Charcot-Marie-Tooth Disease G 60.0
218 Deletion From Autosomes
219 Deletion Of Short Arm Of Chromosome 4
220 Deletion Of Short Arm Of Chromosome 5
221 Delta-Aminolevulinate Dehydratase Deficiency Porphyria -
NA
See ALA Dehydratase Deficiency
222 Dementia - See CADASIL Syndrome NA
223 Demyelinogenic Leukodystrophy - See Alexander Disease ICD 9: 331.89
224 Dent’s Disease
225 Dermatosparactic Type Of Ehlers-Danlos Syndrome - See Ehlers-
Q 79.6
Danlos Syndrome#Dermatosparaxis Type
226 Dermatosparaxis - See Ehlers-Danlos
Q 79.6
Syndrome#Dermatosparaxis Type
227 Desmoid Tumour
228 D-Glycerate Dehydrogenase Deficiency - See Hyperoxaluria,
NA
Primary
229 Dhmn - See Amyotrophic Lateral Sclerosis#Type 4 G 12.2
230 DHMN-V - See Distal Spinal Muscular Atrophy, Type V G 12
231 DHTR Deficiency - See Androgen Insensitivity Syndrome E 34.5
232 Di George’s Syndrome D 82.1

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233 Diabetes Mellitus- Type I
234 Diffuse Globoid Body Sclerosis - See Krabbe Disease E 75.2
235 Dihydrolipoamide Dehydrogenase Deficiency ( = “ E 3 Disease “ )
236 Dihydrotestosterone Receptor Deficiency - See Androgen
E 34.5
Insensitivity Syndrome
237 Distal Spinal Muscular Atrophy, Type V G 12
238 DM1 - See Myotonic Dystrophy#Type 1 G 71.1
239 DM2 - See Myotonic Dystrophy#Type 2 G 71.1
240 Down Syndrome Q 90
241 DSMAV - See Distal Spinal Muscular Atrophy, Type V G 71.0
242 DSN - See Charcot-Marie-Tooth Disease#Type 4 G 60.0
243 DSS - See Charcot-Marie-Tooth Disease, Type 4 G 60.0
244 Duchenne/Becker Muscular Dystrophy - See Muscular Dystrophy,
G 71.0
Duchenne And Becker Type
245 Dwarf, Achondroplastic - See Achondroplasia Q 77.4
246 Dwarf, Thanatophoric - See Thanatophoric Dysplasia Q 77.1
247 Dwarfism E 23.0
248 Dwarfism-Retinal Atrophy-Deafness Syndrome - See Cockayne
Q 87.1
Syndrome
249 Dysmyelinogenic Leukodystrophy -See Alexander Disease ICD 9: 331.89
250 Dystrophia Myotonica - See Myotonic Dystrophy G 71.1
251 Dystrophia Retinae Pigmentosa-Dysostosis Syndrome - See Usher
NA
Syndrome
252 Early-Onset Familial Alzheimer Disease (EOFAD) - See Alzheimer
G 30.0
Disease#Type 1; #Type 3; #Type 4
253 Eczema
254 EDS - See Ehlers-Danlos Syndrome Q 79.6
255 Ehlers-Danlos Syndrome Q 79.6
256 Ekman-Lobstein Disease - See Osteogenesis Imperfecta Q 78.0
257 Entrapment Neuropathy- See Hereditary Neuropathy With
ICD 9: 355.9
Liability To Pressure Palsies
258 Ependymoblastoma
259 Epidermolysis Bullosa Acquisita
260 Epiloia-See Tuberous Sclerosis Q 85.1
261 EPP-See Erythropoietic Protoporphyria E 80.0
262 Erythroblastic Anemia D 56.1
263 Erythrohepatic Protoporphyria E 80.0
264 Erythroid 5-Aminolevulinate Synthetase Deficiency D 64.0
265 Erythropoietic Porphyria E 80.0

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266 Erythropoietic Protoporphyria E 80.0
267 Erythropoietic Uroporphyria-See Congenital Erythropoietic
E 80.0
Porphyria
268 Exostosis (Multiple)
269 Fabry Disease E 75.2
270 Facial Injuries And Disorders NA
271 Factor V Leiden Thrombophilia ICD 9: 289.81
272 FALS-See Amyotrophic Lateral Sclerosis G 12.2
273 Familial Acoustic Neuroma-See Neurofibromatosis Type II Q 85.0
274 Familial Adenomatous Polyposis C 18; D 12
275 Familial Alzheimer Disease (FAD)-See Alzheimer’s Disease G 30
276 Familial Amyotrophic Lateral Sclerosis-See Amyotrophic Lateral
G 12.2
Sclerosis
277 Familial Dysautonomia G 90.1
278 Familial Fat-Induced Hypertriglyceridemia-See Lipoprotein
NA
Lipase Deficiency, Familial
279 Familial Hemochromatosis-See Hemochromatosis R 79.0
280 Familial LPL Deficiency-See Lipoprotein Lipase Deficiency,
NA
Familial
281 Familial Paroxysmal Polyserositis-See Mediterranean Fever,
E 85.0
Familial
282 Familial PCT-See Porphyria Cutanea Tarda E 80.1
283 Familial Pressure Sensitive Neuropathy-See Hereditary
ICD 9: 355.9
Neuropathy With Liability To Pressure Palsies
284 Familial Primary Pulmonary Hypertension (FPPH)-See Primary
I 27.2
Pulmonary Hypertension
285 Familial Turner Syndrome-See Noonan Syndrome Q 87.1
286 Familial Vascular Leukoencephalopathy-See CADASIL Syndrome NA
287 FAP-See Familial Adenomatous Polyposis C 18, D 12
288 FD-See Familial Dysautonomia G 90.1
289 Female Pseudohermaphroditism
290 Female Pseudo-Turner Syndrome-See Noonan Syndrome Q 87.1
291 Female With 46 XY Karyotype
292 Female With More Than Three X Chromosomes
293 Ferrochelatase Deficiency-See Erythropoietic Protoporphyria E 80.0
294 Ferroportin Disease-See Haemochromatosis#Type 4 R 79.0
295 Fever-See Mediterranean Fever, Familial E 85.0
296 FG Syndrome NA
297 FGFR3-Associated Coronal Synostosis-See Muenke Syndrome Q 75.0

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298 Fibrinoid Degeneration Of Astrocytes-See Alexander Disease ICD 9: 331.89
299 Fibrocystic Disease Of The Pancreas-See Cystic Fibrosis E 84
300 Fibrodysplasia Ossificans
301 FMF-See Mediterranean Fever, Familial E 85.0
302 Folling Disease-See Phenylketonuria E 70.0
303 Fra(X) Syndrome-See Fragile X Syndrome Q 99.2
304 Fragile X Syndrome Q 99.2
305 Fragilitas Ossium-See Osteogenesis Imperfecta Q 78.0
306 FRAXA Syndrome-See Fragile X Syndrome Q 99.2
307 FRDA-See Friedreich’s Ataxia G 11.1
308 Friedreich’s Ataxia G 11.1
309 Friedreich’s Ataxia-See Friedreich’s Ataxia G 11.1
310 FXS-See Fragile X Syndrome Q 99.2
311 G6PD Deficiency D 55.0
312 Galactokinase Deficiency Disease-See Galactosemia E 74.2
313 Galactose-1-Phosphate Uridyl-Transferase Deficiency Disease-
E 74.2
See Galactosemia
314 Galactosemia E 74.2
315 Galactosylceramidase Deficiency Disease-See Krabbe Disease E 75.2
316 Galactosylceramide Lipidosis-See Krabbe Disease E 75.2
317 Galactosylcerebrosidase Deficiency-See Krabbe Disease E 75.2
318 Galactosylsphingosine Lipidosis-See Krabbe Disease E 75.2
319 GALC Deficiency-See Krabbe Disease E 75.2
320 GALT Deficiency-See Galactosemia E 74.2
321 Gastro-Intestinal Stromal
322 Gaucher Disease E 75.2
323 Gaucher-Like Disease-See Pseudo-Gaucher Disease E 75.2
324 GBA Deficiency-See Gaucher Disease Type 1 E 75.2
325 GD-See Gaucher’s Disease E 75.2
326 Genetic Emphysema-See Alpha 1-Antitrypsin Deficiency E 88.0
327 Genetic Hemochromatosis-See Hemochromatosis R 79.0
328 Genetic Hypercalciuria - See Dent’s Disease NA
329 Gestational Trophoblastic
330 Giant Cell Hepatitis, Neonatal-See Neonatal Hemochromatosis R 79.0
331 Gigantism
332 GLA Deficiency-See Fabry Disease ICD 9: 272.7
333 Globoid Cell Leukodystrophy (GCL, GLD)-See Krabbe Disease E 75.2
334 Globoid Cell Leukoencephalopathy-See Krabbe Disease E 75.2

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335 Glucocerebrosidase Deficiency-See Gaucher Disease E 75.2
336 Glucocerebrosidosis-See Gaucher Disease E 75.2
337 Glucosyl Cerebroside Lipidosis-See Gaucher Disease E 75.2
338 Glucosylceramidase Deficiency-See Gaucher Disease E 75.2
339 Glucosylceramide Beta-Glucosidase Deficiency-See Gaucher
E 75.2
Disease
340 Glucosylceramide Lipidosis-See Gaucher Disease E 75.2
341 Glyceric Aciduria-See Hyperoxaluria, Primary NA
342 Glycine Encephalopathy-See Nonketotic Hyperglycinemia NA
343 Glycolic Aciduria-See Hyperoxaluria, Primary NA
344 GM2 Gangliosidosis, Type 1-See Tay-Sachs Disease E 75.0
345 Goiter-Deafness Syndrome-See Pendred Syndrome NA
346 Graefe-Usher Syndrome-See Usher Syndrome NA
347 Granulosa Cell Tumour (Of Ovary)
348 Gronblad-Strandberg Syndrome-See Pseudoxanthoma Elasticum Q 82.8
349 Guenther Porphyria-See Congenital Erythropoietic Porphyria E 80.0
350 Gunther Disease-See Congenital Erythropoietic Porphyria E 80.0
351 Haemochromatosis/Hemochromatosis/Hemochromatoses R 79.0
352 Haemoglobinuria (PNH)
353 Haemophilia/Hemophilia D 66
354 Hairy Cell Leukemia
355 Hallgren Syndrome-See Usher Syndrome NA
356 Harlequin Type Ichthyosis Q 80.4
357 Hashimoto’s Disease (=Thyroiditis)
358 Hb S Disease-See Sickle Cell Anemia D 57
359 HCH-See Hypochondroplasia Q 77.4
360 HCP-See Hereditary Coproporphyria E 80.2
361 Head And Brain Malformations
362 Hearing Disorders And Deafness
363 Hearing Problems In Children
364 HEF2A-See Hemochromatosis#Type 2 R 79.0
365 HEF2B-See Hemochromatosis#Type 2 R 79.0
366 Hematoporphyria-See Porphyria E 80.0
367 Heme Synthetase Deficiency-See Erythropoietic Protoporphyria E 80.0
368 Hemoglobin M Disease-See Methemoglobinemia#Beta-Globin
D 74
Type
369 Hemoglobin S Disease-See Sickle Cell Anemia D 57
370 Hepatic AGT Deficiency-See Hyperoxaluria, Primary NA

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371 Hepatoerythropoietic Porphyria E 80.2
372 Hepatolenticular Degeneration Syndrome-See Wilson Disease E 83.0
373 HEP-See Hepatoerythropoietic Porphyria E 80.2
374 Hereditary Nonpolyposis
375 Hereditary Arthro-Ophthalmopathy-See Stickler Syndrome Q 87.8
376 Hereditary Coproporphyria E 80.2
377 Hereditary Dystopic Lipidosis-See Fabry Disease E 75.2
378 Hereditary Hemochromatosis (HHC)-See Hemochromatosis R 79.0
379 Hereditary Inclusion Body Myopathy-See Skeletal Muscle
NA
Regeneration
380 Hereditary Iron-Loading Anemia-See X-Linked Sideroblastic
D 64.0
Anemia
381 Hereditary Motor And Sensory Neuropathy-See Charcot-Marie-
G 60.0
Tooth Disease
382 Hereditary Motor Neuronopathy, Type V-See Distal Spinal
G 12
Muscular Atrophy, Type V
383 Hereditary Motor Neuronopathy-See Spinal Muscular Atrophy G 12
384 Hereditary Multiple Exostoses Q 78.6
385 Hereditary Periodic Fever Syndrome-See Mediterranean Fever,
E 85.0
Familial
386 Hereditary Polyposis Coli-See Familial Adenomatous Polyposis C 18; D 12
387 Hereditary Pulmonary Emphysema-See Alpha 1-Antitrypsin
E 88.0
Deficiency
388 Hereditary Resistance To Activated Protein C-See Factor V Leiden
ICD 9: 289.81
Thrombophilia
389 Hereditary Sensory And Autonomic Neuropathy Type III-
G 90.1
See Familial Dysautonomia
390 Hereditary Spastic Paraplegia-See Infantile-Onset Ascending
G 11.4
Hereditary Spastic Paralysis
391 Hereditary Spinal Ataxia-See Friedreich’s Ataxia G 11.1
392 Hereditary Spinal Sclerosis-See Friedreich’s Ataxia G 11.1
393 Hermaphroditism
394 Herrick’s Anemia-See Sickle Cell Anemia D 57
395 Heterozygous OSMED-See Weissenbacher-Zweymüller Syndrome NA
396 Heterozygous Otospondylomegaepiphyseal Dysplasia-
NA
See Weissenbacher-Zweymüller Syndrome
397 Hexa Deficiency-See Tay-Sachs Disease E 75.0
398 Hexosaminidase A Deficiency-See Tay-Sachs Disease E 75.0
399 Hexosaminidase Alpha-Subunit Deficiency (Variant B)-See Tay-
E 75.0
Sachs Disease

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400 HFE-Associated Hemochromatosis-See Hemochromatosis R 79.0
401 HGPS-See Progeria E 34.8
402 Hidradenitis Suppurativa (Hidradenoma)
403 Hippel-Lindau Disease-See Von Hippel-Lindau Disease Q 85.8
404 Hirschsprung’s Disease
405 HLAH-See Hemochromatosis R 79.0
406 HMN V-See Distal Spinal Muscular Atrophy, Type V G 12
407 HMSN-See Charcot-Marie-Tooth Disease G 60.0
408 HNPP-See Hereditary Neuropathy With Liability To Pressure
ICD 9: 355.9
Palsies
409 Hodgkin’s Lymphoma
410 Homocystinuria E 72.1
411 Homogentisic Acid Oxidase Deficiency-See Alkaptonuria E 70.2
412 Homogentisic Acidura-See Alkaptonuria E 70.2
413 Homozygous Porphyria Cutanea Tarda-See Hepatoerythropoietic
E 80.2
Porphyria
414 HP1-See Hyperoxaluria, Primary NA
415 HP2-See Hyperoxaluria, Primary NA
416 HPA-See Hyperphenylalaninemia E 70.0
417 HPRT - Hypoxanthine-Guanine Phosphoribosyltransferase
E 79.1
Deficiency-See Lesch-Nyhan Syndrome
418 HSAN Type III-See Familial Dysautonomia G 90.1
419 HSAN3-See Familial Dysautonomia G 90.1
420 HSN-III-See Familial Dysautonomia G 90.1
421 Human Dermatosparaxis-See Ehlers-Danlos
Q 79.6
Syndrome#Dermatosparaxis Type
422 Huntington’s Disease G 10
423 Hutchinson-Gilford Progeria Syndrome-See Progeria E 34.8
424 Hyperandrogenism, Nonclassic Type, Due To 21-Hydroxylase
E 25.0
Deficiency-See 21-Hydroxylase Deficiency
425 Hyperchylomicronemia, Familial-See Lipoprotein Lipase
NA
Deficiency, Familial
426 Hyperglycinemia With Ketoacidosis And Leukopenia-
E 71.1
See Propionic Acidemia
427 Hyperlipoproteinemia Type I-See Lipoprotein Lipase Deficiency,
NA
Familial
428 Hyperoxaluria, Primary NA
429 Hyperphenylalaninaemia-See Hyperphenylalaninemia E 70.0
430 Hyperphenylalaninemia E 70.0

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431 Hypochondrodysplasia-See Hypochondroplasia Q 77.4
432 Hypochondrogenesis Q 77.0
433 Hypochondroplasia Q 77.4
434 Hypochromic Anemia-See X-Linked Sideroblastic Anemia D 64.0
435 Hypocupremia, Congenital-See Menkes Disease E 83.0
436 Hypogammaglobulinaemia
437 Hypokalaemic Periodic Paralysis
438 Hypoplastic Anaemia
439 Hypothalamic & Visual Pathway Glioma
440 Hypoxanthine Phosphoribosyltransferse (HPRT) Deficiency-
E 79.1
See Lesch-Nyhan Syndrome
441 IAHSP-See Infantile-Onset Ascending Hereditary Spastic Paralysis NA
442 Idiopathic Thrombocytopaenic Purpura
443 Idiopathic Hemochromatosis-See Hemochromatosis, Type 3 R 79.0
444 Idiopathic Neonatal Hemochromatosis-See Hemochromatosis,
R 79.0
Neonatal
445 Idiopathic Pulmonary Hypertension-See Primary Pulmonary
I 27.0
Hypertension
446 Immune System Disorders-See X-Linked Severe Combined
D 80.0
Immunodeficiency
447 Incontinentia Pigmenti Q 82.3
448 Indeterminate Sex
449 Individual With Autosomal Fragile Site
450 Individuals With Marker Heterochromatin
451 Infantile Cerebral Gaucher’s Disease-See Gaucher Disease Type 2 E 75.2
452 Infantile Gaucher Disease-See Gaucher Disease Type 2 E 75.2
453 Infantile-Onset Ascending Hereditary Spastic Paralysis NA
454 Inherited Emphysema-See Alpha 1-Antitrypsin Deficiency E 88.0
455 Inherited Human Transmissible Spongiform Encephalopathies-
A 81
See Prion Disease
456 Inherited Tendency To Pressure Palsies-See Hereditary
ICD 9: 355.9
Neuropathy With Liability To Pressure Palsies
457 Insley-Astley Syndrome-See Otospondylomegaepiphyseal
NA
Dysplasia
458 Intermittent Acute Porphyria Syndrome-See Acute Intermittent
E 80.2
Porphyria
459 Intestinal Polyposis-Cutaneous Pigmentation Syndrome-
Q 85.8
See Peutz–Jeghers Syndrome
460 IP-See Incontinentia Pigmenti Q 82.3
461 Iron Storage Disorder-See Hemochromatosis R 79.0

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462 Isodicentric 15-See Isodicentric 15 NA
463 Isolated Deafness-See Nonsyndromic Deafness NA
464 Jackson-Weiss Syndrome NA
465 JH-See Haemochromatosis#Type 2 R 79.0
466 Joubert Syndrome Q 04.3
467 JPLS-See Juvenile Primary Lateral Sclerosis NA
468 Juvenile Spondyloarthritis
469 Juvenile Amyotrophic Lateral Sclerosis-See Amyotrophic Lateral
G 12.2
Sclerosis#Type 2
470 Juvenile Gout, Choreoathetosis, Mental Retardation Syndrome-
E 79.1
See Lesch-Nyhan Syndrome
471 Juvenile Hyperuricemia Syndrome-See Lesch-Nyhan Syndrome E 79.1
472 JWS-See Jackson-Weiss Syndrome NA
473 Karyotype 45 X
474 Karyotype 46 X Iso (Xq)
475 Karyotype 46 X With Abnormal Sex Chromosome Except Iso (Xq)
476 Karyotype 47 XXX
477 Karyotype 47 XYY
478 KD-See X-Linked Spinal-Bulbar Muscle Atrophy G 12.1
479 Kennedy Disease-See X-Linked Spinal-Bulbar Muscle Atrophy G 12.1
480 Kennedy Spinal And Bulbar Muscular Atrophy-See X-Linked
G 12.1
Spinal-Bulbar Muscle Atrophy
481 Kerasin Histiocytosis-See Gaucher Disease E 75.2
482 Kerasin Lipoidosis-See Gaucher Disease E 75.2
483 Kerasin Thesaurismosis-See Gaucher Disease E 75.2
484 Ketotic Glycinemia-See Propionic Acidemia E 71.1
485 Ketotic Hyperglycinemia-See Propionic Acidemia E 71.1
486 Kidney Diseases-See Hyperoxaluria, Primary NA
487 Klinefelter Syndrome Karyotype 47 XXY
488 Klinefelter Syndrome Male With More Than Two X Chromosomes
489 Klinefelter’s Syndrome Q 98.4
490 Klinefelter’s Syndrome Male With 46XX Karyotype
491 Klippel-Feil Syndrome (In Young Age)
492 Kniest Dysplasia Q 77.8
493 Krabbe Disease E 75.2
494 Lacunar Dementia-See CADASIL Syndrome NA
495 Landau-Klefner Syndrome
496 Langer-Saldino Achondrogenesis-See Achondrogenesis, Type II Q 77.0
497 Langer-Saldino Dysplasia-See Achondrogenesis, Type II Q 77.0

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498 Late-Onset Alzheimer Disease-See Alzheimer Disease#Type 2 G 30.1
499 Late-Onset Familial Alzheimer Disease (AD2)-See Alzheimer
G 30.1
Disease#Type 2
500 Late-Onset Krabbe Disease (LOKD)-See Krabbe Disease E 75.2
501 Learning Disorders-See Learning Disability F 81.9
502 Lentiginosis, Perioral-See Peutz-Jeghers Syndrome Q 85.8
503 Lesch-Nyhan Syndrome E 79.1
504 Leukodystrophies E 71.3; E 75.2
505 Leukodystrophy With Rosenthal Fibers-See Alexander Disease ICD 9: 331.89
506 Leukodystrophy, Spongiform-See Canavan Disease E 75.2
507 LFS-See Li-Fraumeni Syndrome ICD 9: 758.3
508 Liddle’s Disease
509 Li-Fraumeni Syndrome ICD 9: 758.3
510 Lipase D Deficiency-See Lipoprotein Lipase Deficiency, Familial NA
511 LIPD Deficiency-See Lipoprotein Lipase Deficiency, Familial NA
512 Lipidosis, Cerebroside-See Gaucher Disease E 75.2
513 Lipidosis, Ganglioside, Infantile-See Tay-Sachs Disease E 75.0
514 Lipoid Histiocytosis (Kerasin Type)-See Gaucher Disease E 75.2
515 Lipoprotein Lipase Deficiency, Familial NA
516 Lobulated Fused And Horseshoe Kidney
517 Lou Gehrig Disease-See Amyotrophic Lateral Sclerosis G 12.2
518 Louis-Bar Syndrome-See Ataxia Telangiectasia G 11.3
519 Lymphangioleiomyomatosis …...............
520 Lysyl-Hydroxylase Deficiency-See Ehlers-Danlos
Q 79.6
Syndrome#Kyphoscoliosis Type
521 Machado-Joseph Disease-See Spinocerebellar Ataxia#Type 3 G 11
522 Majeed Syndrome
523 Male Genital Disorders NA
524 Male Pseudohermaphroditism
525 Male Turner Syndrome-See Noonan Syndrome Q 87.1
526 Male With Sex Chromosome Mosaicism
527 Male With Structurally Abnormal Sex Chromosome
528 Marfan Syndrome Q 87.4
529 Marker X Syndrome-See Fragile X Syndrome Q 99.2
530 Martin-Bell Syndrome-See Fragile X Syndrome Q 99.2
531 Mccune – ALBRIGHT SYNDROME
532 Mccune–Albright Syndrome Q 78.1
533 Mcleod Syndrome NA
534 Meckel ‘S Diverticulum

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535 Mediterranean Anemia-See Beta-Thalassemia D 56.1
536 Mediterranean Fever, Familial E 85.0
537 Mednik [5] NA
538 Mega-Epiphyseal Dwarfism-See Otospondylomegaepiphyseal
NA
Dysplasia
539 Menkea Syndrome-See Menkes Disease E 83.0
540 Menkes Disease E 83.0
541 Mental Retardation With Osteocartilaginous Abnormalities-
ICD 9: 759.89
See Coffin-Lowry Syndrome
542 Metabolic Disorders E 70 to E 90
543 Metatropic Dwarfism, Type II-See Kniest Dysplasia Q 77.8
544 Metatropic Dysplasia Type II-See Kniest Dysplasia Q 77.8
545 Methemoglobinemia#Beta-Globin Type D 74
546 Methylmalonic Acidemia E 71.1
547 MFS-See Marfan Syndrome Q 87.4
548 MHAM-See Cowden Syndrome ICD 9: 759.6
549 Micro Syndrome NA
550 Microcephaly Q 02
551 Minor Partial Trisomy
552 Mixed Connective Tissue Disease
553 MK-See Menkes Disease E 83.0
554 MMA-See Methylmalonic Acidemia E 71.1
555 MNK-See Menkes Disease E 83.0
556 Monosomy 1p36 Syndrome-See 1p36 Deletion Syndrome NA
557 Monosomy X-See Turner Syndrome Q 96
558 Mosaicism 45 X/ Cell Line(S) With Abnormal Sex Chromosome
559 Mosaicism 45 X/46 XX Or XY
560 Mosaicism Lines With Various Numbers Of X Chromosomes
561 Movement Disorders F 44.4, F 98.4,
G 25.8 to G
25.9, R 25
562 Mowat-Wilson Syndrome NA
563 Mucopolysaccharidosis (MPS I) E 76
564 Mucoviscidosis - See Cystic Fibrosis E 84
565 Muenke Syndrome Q 75.0
566 Multi-Infarct Dementia - See CADASIL Syndrome NA
567 Multiple Carboxylase Deficiency, Late-Onset - See Biotinidase
ICD 9: 277.6
Deficiency
568 Multiple Hamartoma Syndrome - See Cowden Syndrome ICD 9: 759.6

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569 Multiple Neurofibromatosis - See Neurofibromatosis Q 85.0
570 Muscular Dystrophy G 71.0
571 Muscular Dystrophy, Duchenne And Becker Type G 71.0
572 Myeloproliferative Disorder
573 Myotonia Atrophica - See Myotonic Dystrophy G 71.1
574 Myotonia Dystrophica - See Myotonic Dystrophy G 71.1
575 Myotonic Dystrophy G 71.1
576 Myxedema, Congenital - See Congenital Hypothyroidism E 00
577 Nance-Insley Syndrome - See Otospondylomegaepiphyseal
NA
Dysplasia
578 Nance-Sweeney Chondrodysplasia -
NA
See Otospondylomegaepiphyseal Dysplasia
579 Narcolepsy
580 NBIA1 - See Pantothenate Kinase-Associated Neurodegeneration G 23.0
581 Neill-Dingwall Syndrome - See Cockayne Syndrome Q 87.1
582 Neurodegeneration With Brain Iron Accumulation Type 1 -
G 23.0
See Pantothenate Kinase-Associated Neurodegeneration
583 Neurofibromatosis Type I Q 85.0
584 Neurofibromatosis Type II Q 85.0
585 Neuronopathy, Distal Hereditary Motor, Type V - See Distal Spinal
NA
Muscular Atrophy#Type V
586 Neuronopathy, Distal Hereditary Motor, With Pyramidal Features
G 12.2
- See Amyotrophic Lateral Sclerosis#Type 4
587 Niemann–Pick Disease E 75.2
588 Noack Syndrome - See Pfeiffer Syndrome Q 87.7
589 Nonketotic Hyperglycinemia - See Glycine Encephalopathy NA
590 Non-Neuronopathic Gaucher Disease - See Gaucher Disease Type
E 75.2
1
591 Non-Phenylketonuric Hyperphenylalaninemia -
E 70.0
See Tetrahydrobiopterin Deficiency
592 Nonsyndromic Deafness NA
593 Noonan Syndrome Q 87.1
594 Norrbottnian Gaucher Disease - See Gaucher Disease Type 3 E 75.2
595 Ochronosis - See Alkaptonuria E 70.2
596 Ochronotic Arthritis - See Alkaptonuria E 70.2
597 OI - See Osteogenesis Imperfecta Q 78.0
598 OSMED - See Otospondylomegaepiphyseal Dysplasia NA
599 Osteogenesis Imperfecta - Q 78.0
600 Osteopsathyrosis - See Osteogenesis Imperfecta Q 78.0

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Sl. No GENETIC DISORDERS ICD 10 Codes

601 Osteosclerosis Congenita - See Achondroplasia Q 77.4
602 Otospondylomegaepiphyseal Dysplasia NA
603 Oto-Spondylo-Megaepiphyseal Dysplasia -
NA
See Otospondylomegaepiphyseal Dysplasia
604 Oxalosis - See Hyperoxaluria, Primary NA
605 Oxaluria, Primary - See Hyperoxaluria, Primary NA
606 Pantothenate Kinase-Associated Neurodegeneration G 23.0
607 Paroxysmal Nocturnal Haemoglobinuria (Pnh)
608 Q 91.4 to Q
Patau Syndrome (Trisomy 13)
91.7
609 PBGD Deficiency - See Acute Intermittent Porphyria E 80.2
610 PCC Deficiency - See Propionic Acidemia E 71.1
611 PCT - See Porphyria Cutanea Tarda E 80.1
612 PDM - See Myotonic Dystrophy#Type 2 G 71.1
613 Pendred Syndrome NA
614 Periodic Limb Movements In Sleep Btbd 9 On Chro. 6p 21.2
615 Periodic Disease - See Mediterranean Fever, Familial E 85.0
616 Periodic Peritonitis - See Mediterranean Fever, Familial E 85.0
617 Periorificial Lentiginosis Syndrome - See Peutz-Jeghers Syndrome Q 85.8
618 Peripheral Nerve Disorders - See Familial Dysautonomia G 90.1
619 Peripheral Neurofibromatosis - See Neurofibromatosis Type I Q 85.0
620 Peroneal Muscular Atrophy - See Charcot-Marie-Tooth Disease G 60.0
621 Peroxisomal Alanine:Glyoxylate Aminotransferase Deficiency -
NA
See Hyperoxaluria, Primary
622 Peutz-Jeghers Syndrome Q 85.8
623 Pfeiffer Syndrome Q 87.7
624 Phenylalanine Hydroxylase Deficiency Disease -
E 70.0
See Phenylketonuria
625 Phenylketonuria E 70.0
626 Pheochromocytoma - See Von Hippel-Lindau Disease Q 85.8
627 Pierre Robin Syndrome With Fetal Chondrodysplasia -
NA
See Weissenbacher-Zweymüller Syndrome
628 Pigmentary Cirrhosis - See Hemochromatosis R 79.0
629 Pjs - See Peutz-Jeghers Syndrome Q 85.8
630 Pkan - See Pantothenate Kinase-Associated Neurodegeneration G 23.0
631 Pku - See Phenylketonuria E 70.0
632 Plumboporphyria - See Ala Deficiency Porphyria NA
633 Pma - See Charcot-Marie-Tooth Disease G 60.0
634 Polycystic Kidney Disease

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635 Polycystic Kidney Adult Type
636 Polycystic Kidney Infantile Type
637 Polycythaemia Vera Rubra
638 Polyostotic Fibrous Dysplasia - See Mccune–Albright Syndrome Q 78.1
639 Polyposis Coli - See Familial Adenomatous Polyposis C 18, D 12
640 Polyposis, Hamartomatous Intestinal - See Peutz-Jeghers
Q 85.8
Syndrome
641 Polyposis, Intestinal, Ii - See Peutz-Jeghers Syndrome Q 85.8
642 Polyps-And-Spots Syndrome - See Peutz-Jeghers Syndrome Q 85.8
643 Polyserositis
644 Porphobilinogen Synthase Deficiency - See Ala Deficiency
NA
Porphyria
645 Porphyria E 80.0 to E 80.2
646 Porphyrin Disorder - See Porphyria E 80.0 to E 80.3
647 PPH - See Primary Pulmonary Hypertension I 27.0
648 PPOX Deficiency - See Variegate Porphyria E 80.2
649 Prader-Labhart-Willi Syndrome - See Prader-Willi Syndrome Q 87.1
650 Prader-Willi Syndrome Q 87.1
651 Presenile And Senile Dementia - See Alzheimer’s Disease G 30
652 Primary Hemochromatosis - See Hemochromatosis R 79.0
653 Primary Hyperuricemia Syndrome - See Lesch-Nyhan Syndrome E 79.1
654 Primary Pulmonary Hypertension I 27.0
655 Primary Senile Degenerative Dementia - See Alzheimer’s Disease G 30
656 Prion Disease A 81
657 Procollagen Type EDS VII, Mutant - See Ehlers-Danlos
Q 79.6
Syndrome#Arthrochalasia Type
658 Progeria - See Hutchinson Gilford Progeria Syndrome E 34.8
659 Progeria-Like Syndrome - See Cockayne Syndrome Q 87.1
660 Progeroid Nanism - See Cockayne Syndrome Q 87.1
661 Progressive Chorea, Chronic Hereditary (Huntington) -
G 10
See Huntington’s Disease
662 Progressive Muscular Atrophy - See Spinal Muscular Atrophy G 12
663 Progressively Deforming Osteogenesis Imperfecta With Normal
Q 78.0
Sclerae - See Osteogenesis Imperfecta#Type III
664 PROMM - See Myotonic Dystrophy#Type 2 G 71.1
665 Propionic Acidemia E 71.1
666 Propionyl-Coa Carboxylase Deficiency - See Propionic Acidemia E 71.1
667 Protein C Deficiency ICD 9: 289.81
668 Protein S Deficiency ICD 9: 289.82

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669 Protoporphyria - See Erythropoietic Protoporphyria E 80.0
670 Protoporphyrinogen Oxidase Deficiency - See Variegate Porphyria E 80.2
671 Proximal Myotonic Dystrophy - See Myotonic Dystrophy#Type 2 G 71.1
672 Proximal Myotonic Myopathy - See Myotonic Dystrophy#Type 2 G 71.1
673 Pseudo-Gaucher Disease E 75.2
674 Pseudohermaphroditism
675 Pseudo-Ullrich-Turner Syndrome - See Noonan Syndrome Q 87.1
676 Pseudoxanthoma Elasticum Q 82.8
677 Psoriatic Arthritis
678 Psychosine Lipidosis - See Krabbe Disease E 75.2
679 Pulmonary Arterial Hypertension - See Primary Pulmonary
I 27.0
Hypertension
680 Pulmonary Hypertension - See Primary Pulmonary Hypertension I 27.0
681 PWS - See Prader-Willi Syndrome Q 87.1
682 PXE - Pseudoxanthoma Elasticum - See Pseudoxanthoma
Q 82.8
Elasticum
683 Recklinghausen Disease, Nerve - See Neurofibromatosis Type I Q 85.0
684 Recurrent Polyserositis - See Mediterranean Fever, Familial E 85.0
685 Renal Agenesis Unilateral/Bilateral
686 Renal Hypoplasia Unilateral/Bilateral
687 Restless Leg Syndrome
688 Retinitis Pigmentosa-Deafness Syndrome - See Usher Syndrome NA
689 Rett Syndrome F 84.2
690 RFALS Type 3 - See Amyotrophic Lateral Sclerosis#Type 2 G 12.2
691 Ricker Syndrome - See Myotonic Dystrophy#Type 2 G 71.1
692 Riley-Day Syndrome - See Familial Dysautonomia G 90.1
693 Roussy-Levy Syndrome - See Charcot-Marie-Tooth Disease G 60.0
694 RSTS - See Rubinstein-Taybi Syndrome Q 87.2
695 RTS - See Rett Syndrome (F 84.2); See Rubinstein-Taybi Syndrome
F 84.2/ Q 87.2
(Q 87.2)
696 RTT - See Rett Syndrome F 84.2
697 Rubinstein-Taybi Syndrome Q 87.2
698 Sack-Barabas Syndrome - See Ehlers-Danlos Syndrome, Vascular
Q 79.6
Type
699 Saddan NA
700 SBLA Syndrome - See Li-Fraumeni Syndrome ICD 9: 758.3
701 SBMA - See X-Linked Spinal-Bulbar Muscle Atrophy G 12.1
702 SCD - See Sickle Cell Anemia D 57
703 Schmidt Syndrome

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704 Schwannoma, Acoustic, Bilateral - See Neurofibromatosis Type II Q 85.0
705 SCIDX1 - See X-Linked Severe Combined Immunodeficiency D 80.0
706 Sclerosis Tuberosa - See Tuberous Sclerosis Q 85.1
707 SDAT - See Alzheimer’s Disease G 30
708 Secondary Progressive Multiple Sclerosis
709 SED Congenita - See Spondyloepiphyseal Dysplasia Congenita Q 77.7
710 SED Strudwick - See Spondyloepimetaphyseal Dysplasia,
NA
Strudwick Type
711 Sedc - See Spondyloepiphyseal Dysplasia Congenita Q 77.7
712 See Beta-Thalassemia D 56.1
713 See Congenital Erythropoietic Porphyria E 80.0
714 See Erythropoietic Protoporphyria E 80.0
715 See Hereditary Neuropathy With Liability To Pressure Palsies ICD 9: 355.9
716 See X-Linked Sideroblastic Anemia D 64.0
717 SEMD, Strudwick Type - See Spondyloepimetaphyseal Dysplasia,
NA
Strudwick Type
718 Senile Dementia - See Alzheimer Disease#Type 2 G 30
719 Severe Achondroplasia With Developmental Delay And
NA
Acanthosis Nigricans - See SADDAN
720 Severe Combined Immunodeficiency
721 Sex Chromosome Abnormality Female Phenotype
722 Sex Chromosome Abnormality Male Phenotype
723 Short ‘Qt’ Syndrome
724 Shprintzen Syndrome - See 22q11.2 Deletion Syndrome D 82.1
725 Sickle Cell Disease
726 Sickle Cell Anemia D 57
727 Siderius X-Linked Mental Retardation Syndrome - Caused By
NA
Mutations In The PHF8 Gene
728 Sjorgens Syndrome
729 Skeleton-Skin-Brain Syndrome - See SADDAN NA
730 Skin Pigmentation Disorders NA
731 SMA - See Spinal Muscular Atrophy G 12
732 SMED, Strudwick Type - See Spondyloepimetaphyseal Dysplasia,
NA
Strudwick Type
733 SMED, Type I - See Spondyloepimetaphyseal Dysplasia, Strudwick
NA
Type
734 Smith-Lemli-Opitz Syndrome Q 87.1
735 South-African Genetic Porphyria - See Variegate Porphyria E 80.2
736 Spastic Paralysis, Infantile Onset Ascending - See Infantile-Onset
NA
Ascending Hereditary Spastic Paralysis

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737 Speech And Communication Disorders NA
738 Spherocytosis (Heriditary)
739 Sphingolipidosis, Tay-Sachs - See Tay-Sachs Disease E 75.0
740 Spinal Muscular Atrophy G 12
741 Spinal Muscular Atrophy, Distal Type V - See Distal Spinal
G 12
Muscular Atrophy#Type V
742 Spinal Muscular Atrophy, Distal, With Upper Limb Predominance
G 12
- See Distal Spinal Muscular Atrophy#Type V
743 Spinal-Bulbar Muscular Atrophy NA
744 Spinocerebellar Ataxia G 11
745 Spondyloarthropathy
746 Spondyloepimetaphyseal Dysplasia, Strudwick Type NA
747 Spondyloepiphyseal Dysplasia - See Collagenopathy, Types II And
NA
XI
748 Spondyloepiphyseal Dysplasia Congenita Q 77.7
749 Spondylometaepiphyseal Dysplasia Congenita, Strudwick Type -
NA
See Spondyloepimetaphyseal Dysplasia, Strudwick Type
750 Spondylometaphyseal Dysplasia (SMD) -
NA
See Spondyloepimetaphyseal Dysplasia, Strudwick Type
751 Spondylometaphyseal Dysplasia, Strudwick Type -
NA
See Spondyloepimetaphyseal Dysplasia, Strudwick Type
752 Spongy Degeneration Of Central Nervous System - See Canavan
E 75.2
Disease
753 Spongy Degeneration Of The Brain - See Canavan Disease E 75.2
754 Spongy Degeneration Of White Matter In Infancy - See Canavan
E 75.2
Disease
755 Sporadic Primary Pulmonary Hypertension - See Primary
I 27.0
Pulmonary Hypertension
756 Sprengel’s Deformity
757 SSB Syndrome - See SADDAN NA
758 Steely Hair Syndrome - See Menkes Disease E 83.0
759 Steinert Disease - See Myotonic Dystrophy G 71.1
760 Steinert Myotonic Dystrophy Syndrome - See Myotonic Dystrophy G 71.1
761 Stickler Syndrome Q 87.8
762 Stiff Person Syndromme
763 Stroke - See CADASIL Syndrome NA
764 Strudwick Syndrome - See Spondyloepimetaphyseal Dysplasia,
NA
Strudwick Type
765 Subacute Neuronopathic Gaucher Disease - See Gaucher Disease
E 75.2
Type 3

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766 Swedish Genetic Porphyria - See Acute Intermittent Porphyria E 80.2
767 Swedish Porphyria - See Acute Intermittent Porphyria E 80.2
768 Sweet ‘ S Syndrome
769 Swiss Cheese Cartilage Dysplasia - See Kniest Dysplasia Q 77.8
770 Swyer Syndrome
771 Systemic Sclerosis
772 Systemic Lupus Erythematosus
773 Tay-Sachs Disease E 75.0
774 TD - Thanatophoric Dwarfism - See Thanatophoric Dysplasia Q 77.1
775 TD With Straight Femurs And Cloverleaf Skull - See Thanatophoric
Q 77.1
Dysplasia#Type 2
776 Telangiectasia, Cerebello-Oculocutaneous - See Ataxia
G 11.3
Telangiectasia
777 Testicular Feminization Syndrome - See Androgen Insensitivity
E 34.5
Syndrome
778 Tetrahydrobiopterin Deficiency E 70.1
779 TFM - Testicular Feminization Syndrome - See Androgen
E 34.5
Insensitivity Syndrome
780 Thalassaemia Alpha-Type
781 Thalassaemia Beta-Type
782 Thalassemia Intermedia - See Beta-Thalassemia D 56.1
783 Thalassemia Major - See Beta-Thalassemia D 56.1
784 Thanatophoric Dysplasia Q 77.1
785 Thiamine-Responsive Megaloblastic Anemia With Diabetes
NA
Mellitus And Sensorineural Deafness
786 Thrombophilia
787 Thrombophilia Due To Deficiency Of Cofactor For Activated
ICD 9: 289.81
Protein C, Leiden Type - See Factor V Leiden Thrombophilia
788 Tomaculous Neuropathy - See Hereditary Neuropathy With
ICD 9: 355.9
Liability To Pressure Palsies
789 Total HPRT Deficiency - See Lesch-Nyhan Syndrome E 79.1
790 Total Hypoxanthine-Guanine Phosphoribosyl Transferase
E 79.1
Deficiency - See Lesch-Nyhan Syndrome
791 Transmissible Dementias - See Prion Disease A 81
792 Transmissible Spongiform Encephalopathies - See Prion Disease A 81
793 Treacher Collins Syndrome Q 75.4
794 Trias Fragilitis Ossium - See Osteogenesis Imperfecta#Type I Q 78.0
795 Triple X Syndrome Q 97.0
796 Triplo X Syndrome - See Triple X Syndrome Q 97.0
797 Triploidy And Polyploidy

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798 Trisomy 13
799 Trisomy 13 Mosaicism (Mitotic Nondisjunction)
800 Trisomy 13 Nonmosaicism (Meiotic Nondisjunction)
801 Trisomy 13 Translocation
802 Trisomy 18
803 Trisomy 18 Mosaicism (Mitotic Nondisjunction)
804 Trisomy 18 Nonmosaicism (Meiotic Nondisjunction)
805 Trisomy 18 Translocation
806 Trisomy 21 - See Down Syndrome Q 90
807 Trisomy 21 Mosaicism (Mitotic Nondisjunction)
808 Trisomy 21 Nonmosaicism (Meiotic Nondisjunction)
809 Trisomy 21 Translocation
810 Trisomy And Partial Trisomy Of Autosomes
811 Trisomy X - See Triple X Syndrome Q 97.0
812 Troisier-Hanot-Chauffard Syndrome - See Hemochromatosis E 83.1
813 TS - See Turner Syndrome Q 96
814 TSD - See Tay-Sachs Disease E 75.0
815 Tses - See Prion Disease A 81
816 Tuberose Sclerosis - See Tuberous Sclerosis Q 85.1
817 Tuberous Sclerosis Q 85.1
818 Tubo-Villous Adenoma
819 Turner Syndrome Q 96
820 Turner Syndrome In Female With X Chromosome - See Noonan
Q 87.1
Syndrome
821 Turner-Like Syndrome - See Noonan Syndrome Q 87.1
822 Turner’s Phenotype, Karyotype Normal - See Noonan Syndrome Q 87.1
823 Turner’s Syndrome - See Turner Syndrome Q 96
824 Type 2 Gaucher Disease - See Gaucher Disease Type 2 E 75.2
825 Type 3 Gaucher Disease - See Gaucher Disease Type 3 E 75.2
826 UDP Glucose 4-Epimerase Deficiency Disease - See Galactosemia E 74.2
827 UDP Glucose Hexose-1-Phosphate Uridylyltransferase Deficiency -
E 74.2
See Galactosemia
828 UDP-Galactose-4-Epimerase Deficiency Disease -
E 74.2
See Galactosemia
829 Ullrich-Noonan Syndrome - See Noonan Syndrome Q 87.1
830 Ullrich-Turner Syndrome - See Turner Syndrome Q 96
831 Undifferentiated Deafness - See Nonsyndromic Deafness NA
832 UPS Deficiency - See Acute Intermittent Porphyria E 80.2
833 Uric Acid Excretion

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834 UROD Deficiency - See Porphyria Cutanea Tarda E 80.1
835 Uroporphyrinogen Decarboxylase Deficiency - See Porphyria
E 80.1
Cutanea Tarda
836 Uroporphyrinogen Synthase Deficiency - See Acute Intermittent
E 80.2
Porphyria
837 UROS Deficiency - See Congenital Erythropoietic Porphyria E 80.0
838 Usher Syndrome NA
839 UTP Hexose-1-Phosphate Uridylyltransferase Deficiency -
E 74.2
See Galactosemia
840 Van Bogaert-Bertrand Syndrome - See Canavan Disease E 75.2
841 Van Der Hoeve Syndrome - See Osteogenesis Imperfecta#Type I Q 78.0
842 Variegate Porphyria E 80.2
843 Velocardiofacial Syndrome - See 22q11.2 Deletion Syndrome D 82.1
844 VHL Syndrome - See Von Hippel-Lindau Disease Q 85.8
845 Vision Impairment And Blindness - See Alström Syndrome NA
846 Vitiligo
847 Von Hippel – Lindau Disease
848 Von Williebrand Disease
849 Von Bogaert-Bertrand Disease - See Canavan Disease E 75.2
850 Von Hippel-Lindau Disease Q 85.8
851 Von Recklenhausen-Applebaum Disease - See Hemochromatosis R 79.0
852 Von Recklinghausen Disease - See Neurofibromatosis Type I Q 85.0
853 VP - See Variegate Porphyria E 80.2
854 Vrolik Disease - See Osteogenesis Imperfecta Q 78.0
855 Waardenburg Syndrome E 70.3
856 Waldenstrom Macroglobulin Aemia
857 Warburg Sjo Fledelius Syndrome - See Micro Syndrome NA
858 WD - See Wilson Disease E 83.0
859 Weissenbacher-Zweymüller Syndrome NA
860 Whole Chromosome Monosomy Mosaicism (Mitotic
Nondisjunction)
861 Whole Chromosome Monosomy Nonmosaicism (Meiotic
Nondisjunction)
862 Whole Chromosome Trisomy Mosaicism
(Mitotic Nondisjunction)
863 Whole Chromosome Trisomy Nonmosaicism
(Meiotic Nondisjunction)
864 Williams Syndrome Q 93.8
865 Wilm’s Tumour

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866 Wilson Disease E 83.0
867 Wilson’s Disease - See Wilson Disease E 83.0
868 Wiskott – Aldrich Syndrome
869 With Subcortical Infarcts And Leukoencephalopathy -
NA
See CADASIL Syndrome
870 With Subcortical Infarcts And Leukoencephalopathy -
NA
See CADASIL Syndrome
871 Wolf Parkinson White Syndrome
872 Wolff Periodic Disease - See Mediterranean Fever, Familial E 85.0
873 Wolf–Hirschhorn Syndrome Q 93.3
874 WZS - See Weissenbacher-Zweymüller Syndrome NA
875 Xeroderma Pigmentosum Q 82.1
876 X-Linked Mental Retardation And Macroorchidism - See Fragile X
Q 99.2
Syndrome
877 X-Linked Primary Hyperuricemia - See Lesch-Nyhan Syndrome E 79.1
878 X-Linked Severe Combined Immunodeficiency D 80.0
879 X-Linked Sideroblastic Anemia D 64.0
880 X-Linked Spinal-Bulbar Muscle Atrophy - See Kennedy’s Disease G 12.1
881 X-Linked Uric Aciduria Enzyme Defect - See Lesch-Nyhan
E 79.1
Syndrome
882 XLSA - See X-Linked Sideroblastic Anemia D 64.0
883 XSCID - See X-Linked Severe Combined Immunodeficiency D 80.0
884 X-SCID - See X-Linked Severe Combined Immunodeficiency D 80.0
885 XXX Syndrome - See Triple X Syndrome Q 97.0
886 XXXX Syndrome - See 48, XXXX Q 97.1
887 XXXXX Syndrome - See 49, XXXXX Q 97.1
888 XXY Syndrome - See Klinefelter’s Syndrome Q 98.4
889 XXY Trisomy - See Klinefelter’s Syndrome Q 98.4
890 XYY Karyotype - See 47,XYY Syndrome Q 98.0
891 XYY Syndrome - See 47,XYY Syndrome Q 98.0
892 YY Syndrome - See 47,XYY Syndrome Q 98.0

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Annexure V
CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A
TO BE FILLED BY THE INSURED (To be Filled in block letters)
The issue of this Form is not to be taken as an admission of liablity

DETAILS OF PRIMARY INSURED:

a) Policy No.: b) Sl. No/ Certificate no.

c) Company/ TPA ID No:

d) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E

SECTION A
e) Address:

City: State:

Pin Code Phone No: Email ID:

DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance: Yes No b) Date of commencement of first Insurance without break: D D M M Y Y Y Y

SECTION B
c) If yes, company name: Policy No.

Sum insured (Rs.) d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date: M M Y Y

Diagnosis: e) Previously covered by any other Mediclaim /Health insurance : : Yes No

f) If yes, company name:

DETAILS OF INSURED PERSON HOSPITALIZED: :

a) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E

b) Gender Male Female c) Age years Y Y Months M M d) Date of Birth D D M M Y Y Y Y

e) Relationship to Primary insured: Self Spouse Child Father Mother Other (Please Specify)

SECTION C
f) Occupation Service Self Employed Home Maker Student Retired Other (Please Specify)

g) Address (if diffrent from above) :

City: State:

Pin Code Phone No: Email ID:

DETAILS OF HOSPITALIZATION: :

a) Name of Hospital where Admited:

b) Room Category occupied: Day care Single occupancy Twin sharing 3 or more beds per room

SECTION D
c) Hospitalization due to: Injury Illness Maternity d) Date of injury / Date Disease first detected /Date of Delivery: D D M M Y Y Y Y

e) Date of Admission: D D M M Y Y f) Time H H M H g) Date of Discharge: D D M M Y Y h) Time: H H : M H

I) If injury give cause: Self inflicted Road Traffic Accident Substance Abuse / Alcohol Consumption I) If Medico legal Yes No

ii) Reported to Police iii. MLC Report & Police FIR attached Yes No j) System of Medicine:

DETAILS OF CLAIM:

a) Details of the Treatment expenses claimed Claim Documents Submitted - Check List:
I. Pre -hospitalization expenses Rs. ii. Hospitalization expenses Rs. Claim form duly signed

Rs. Rs. Copy of the claim intimation, if any

iii. Post-hospitalization expenses iv. Health-Check up cost:
Hospital Main Bill
v. Ambulance Charges: Rs. vi. Others (code): Rs.
Hospital Break-up Bill
Total Rs.
SECTION E

Hospital Bill Payment Receipt

vii. Pre -hospitalization period: days viii. Post -hospitalization period: days
Hospital Discharge Summary
b) Claim for Domiciliary Hospitalization: Yes No (If yes, provide details in annexure) Pharmacy Bill

c) Details of Lump sum / cash benefit claimed: Operation Theater Notes

i. Hospital Daily cash: Rs. ii. Surgical Cash: Rs. ECG

Doctor’s request for investigation
iii. Critical Illness benefit: Rs. iv. Convalescence: Rs.
Investigation Reports (Including CT
v. Pre/Post hospitalization Lump sum benefit: Rs. vi. Others: Rs. / MRI / USG / HPE)
Doctor’s Prescriptions
Total Rs.
Others
DETAILS OF BILLS ENCLOSED:

Sl. No. Bill No. Date Issued by Towards Amount (Rs)

1. D D M M Y Y Hospital main Bill
2. D D M M Y Y Pre-hospitalization Bills: Nos
SECTION F

3. D D M M Y Y Post-hospitalization Bills: Nos

4. D D M M Y Y Pharmacy Bills
5. D D M M Y Y
6. D D M M Y Y
7. D D M M Y Y
8. D D M M Y Y
9. D D M M Y Y
10. D D M M Y Y

DETAILS OF PRIMARY INSURED’S BANK ACCOUNT::

a) PAN: b) Account Number:

SECTION G

c) Bank Name and Branch:

d) Cheque / DD Payable details: e) IFSC Code:

(IMPORTANT: PLEASE TURN OVER)

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DECLARATION BY THE INSURED:

I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression
or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA /
Insurance Company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made.
I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization

SECTION H
claim, if any.

Date D D M M Y Y Y Y Place: Signature of the Insured

GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the Insurance Company
Enter the social Insurance number or the certificate number of
b) Sl. No/ Certificate No. As allotted by the oraganization
social health insurance scheme
Licence number as allotted by IRDA and printed
c) Company TPA ID No. Enter the TPA ID No. in TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
e) Address Enter the full postal address Include Street, City and Pin code
SECTION B -DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Indicate whether currently covered by another Mediclaim / Tick Yes or No
Insurance? Health Insurance
b) Date of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat
c) Company Name Enter the full name of the Insurance Company Name of the organization in full
Policy No. Enter the policy number As allotted by the Insurance Company
Sum insured Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last four years since Indicate whether hospitalized in the last four years Tick Yes or No
Inception of the contract?
Date Enter the date of Hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously covered by any other Mediclaim / Health Indicate whether previously covered by another mediclaim /
Tick Yes or No
Insurance? Health Insurance
f) Company Name Enter the full name of the Insurance Company Name of the organization in full
SECTION C -DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option, if others, please specify
f) Occupation indicate occupation of patient Tick the right option. If others, please specify.
g) Address Enter the full postal address Include Street, City and Pin code
h) Phone No Enter the phone number of patient Include STD code with telephone number
1) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited Enter the name of hospital Name of hospital in full
b) Room category occupied indicate the room category occupied Tick the right option
c) Hospitalization due to indicate reason of hospitalization Tick the right option
d) Date of injury/Date Disease first detected / Date of Use dd-mm-yy format
Enter the relevant date
Delivery
e) Date of admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh-mm- format
g) Date of discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh-mm- format
I) If injury give cause indicate cause of injury Tick the right option
If Medico legal indicate whether injury is medico legal Tick Yes or No
Reported to Police indicate whether police report was filed Tick Yes or No
MLC Report & Police FIR attached indicate whether MLC report and Police FIR attached Tick Yes or No
j) System of Medicene Enter the system of medicine followed in treating the patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expences Enter the amount claimed as treatment expences In rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization indicate whether claim is for domiciliary hospitalization Tick Yes or No
c) Details of Lump sum/ Cash benifit claimed Enter the amount claimed as lump sum / cash benefit In rupees (Do not enter paise values)
d) Claim documents Submitted-Check List indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amount in rupees
SECTION G - DETAILS OF PRIMARY INSURED’s BANK ACCOUNT
a) PAN Enter the permanent account number As allotted by the Income Tax Department
b) Account Number Enter the Bank account number As allotted by the Bank
c) Bank Name and Branch Enter the Bank name along with the branch Name of the Bank in full
Enter the name of the beneficiary the cheque / DD should be
c) Cheque/ DD payable details Name of the individual / organization in full
made out to
c) IFSC Code Enter the IFSC code of the Bank branch IFSC code of the Bank branch in full
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.

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CLAIM FORM - PART B

TO BE FILLED IN BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liability (To be Filled in block letters)
Please include the original preauthorization request form in lieu of PART A
DETAILS OF HOSPITAL

a) Name of the hospital:

SECTION A
a) Hospital ID: c) Type of Hospital: Network : Non Network : (if non network fill section E)

c) Name of the treating doctor: S U R N A M E F I R S T N A M E M I D D L E N A M E

e) Qualification: f) Registration No. with State Code: g) Phone No.

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient: S U R N A M E F I R S T N A M E M I D D L E N A M E

b) IP Registration Number: c) Gender: Male Female d) Age: Years Y Y Months M M e) Date of birth: D D M M Y Y

SECTION B
f) Date of Admission: D D M M Y Y g) Time: H H M M h) Date of Discharge: D D M M Y Y H H M M

j) Type of Admission: Emergency Planned Day Care Maternity k) If Maternity i) Date of Delivery: D D M M Y Y ii) Gravida Status: :

I) Status at time of discharge: Discharge to home Discharge to another hospital Deceased m) Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

I. Primary Diagnosis i. Procedure 1:

ii. Additional Diagnosis: ii. Procedure 2:

iii. Co-morbidities: iii. Procedure 3:

SECTION C
iv. Co-morbidities: iv. Details of Procedure:

c) Pre-authorization obtained: Yes No d) Pre-authorization Number:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to injury: Yes No I. If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption

ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this: Yes No (If Yes, attach reports) iii. If Medico legal: Yes No iv. Reported to Police Yes No

v. FIR No. vi. If not reported to police give reason:

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed Investigation reports

Original Pre-authorization request CT/MR/USG/HPE investigation reports
Copy of the Pre-authorization approval letter Doctor’s reference slip for investigation
Copy of Photo ID Card of patient Verified by hospital ECG SECTION D

Hospital Discharge summary Pharmacy bills

Operation Theatre Notes MLC reports & Police FIR
Hospital main bill Original death summary from hospital where applicable
Hospital break-up bill Any other, please specify

ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hospital

City: State:
SECTION E

Pin Code: b) Phone No. c) Registration No. with State Code:

d) Hospital PAN: e) Number of inpatient beds f) Facilities available in the hospital i. OT Yes No ii. ICU Yes No

iii. Others:

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact,
our right to claim under this claim shall be forfeited.
SECTION F

Date: D D M M Y Y

Place: Signature and Seal of the Hospital Authority:

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GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF HOSPITAL
a) Name of the hospital: Enter the name of hospital Name of the hospital in full

b) Hospital ID Enter ID number of hospital As allocated by the TPA

c) Type of Hospital Indicate whether in network or non network hospital Tick the right option

c) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualification of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor along with the state code As allocated by the Medical Council of India

g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of patient Name of patient in full
b) IP registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
d) Age Enter age of the patient Number of years and months
e) Date of Birth Enter date of birth Use dd-mm-yy format
f) Date of Admission Enter date of admission Use dd-mm-yy format
g) Time Enter Time of admission Use hh:mm format
h) Date of Discharge Enter date of Discharge Use dd-mm-yy format
i) Time Enter time of Discharge Use hh:mm format
j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option

M) Total claimed amount Indicate the total claimed amount In rupees (Do not enter paise values)
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code

Primary Diagnosis Enter the ICD 10 Code and description of the primary diagnosis Standard Format and Open text
Additional Diagnosis Enter the ICD 10 Code and description of the additional diagnosis Standard Format and Open text
Co-morbidities Enter the ICD 10 Code and description of the Co-morbidities Standard Format and Open text

b) ICD 10 PCS

Procedure 1 Enter the ICD 10 Code and description of the first procedure Standard Format and Open text
Procedure 2 Enter the ICD 10 Code and description of the second procedure Standard Format and Open text
Procedure 3 Enter the ICD 10 Code and description of the third procedure Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text
c) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
d) Pre-authorization Number Enter pre-authorization number As allotted by TPA

e) If authorization by network hospital not obtained, give reason Enter reason for not obtaining pre-authorization number Open text

f) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No

Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/alcohol consumption test
conducted to establish this Indicate whether test conducted Tick Yes or No

Medico Legal Indicate whether injury is medico legal Tick Yes or No

Reported to Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authrities
If not reported to police, give reason Enter reason for not reporting to police Open text
SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone number
Enter the registration number of the Hospital obtained from local body
c) Registration No. with State Code As allocated by the City Corporation / Municipality
like City Corporation / Municipality
d) Hospital PAN Enter the permanent account number As allocated by the Income Tax Department
e) Number of Inpatient beds Enter the number of inpatient beds Digits
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify

SECTION F - DECLARATION BY THE HOSPITAL

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. and stamp

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 The New India Assurance Co. Ltd.

Annexure VI
Insurance Company Name The New India Assurance Company Limited
Name Of The
TPA

Technical / Medical Adjudication sheet

Policy Details : Claims Details :
Product Type/ Claim Control
Code Number
Policy Type Type of claim
Authorization
Policy Number
Amt. (AL)
Insured Name Lodged Amount
Patient Name Paid Amount
Sex & Age Diagnosis
Policy
ICD codes
Inception Date
Policy Start
Name Of Hospital
Date
Policy End Date Hospital Address
PPN/NON PPN
Policy Coverage
hospital
Sum Insured
Date Of
& Cumulative
Admission
Bonus
Applicable Sum Date Of
Insured Discharge
Balance Sum
Insured
Bill Details Amount Details
Bill Bill Bill Deduction
Sr Bill Amt Deduction Payable
Date Number Particular Reason
1
2
3
4
5
6
Transition
Settlement Transition ID Date /
Date / Cheque No Cheque
Date
Hospital Dis- Deduction Deduction
count Amount Amount Details
Admissibility
Of Claim As Final
Per Policy Approved
Terms And Amount
Conditions

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Annexure VII

Repudiation Statement
Non Cash Less Claim Policy No.
Dev. / Agent Code : IC Branch Code : The New India Assurance Company Limited

To, CCN :
Policy Holder:
Address: Patient Name :
Email ID Employee Details :
Phone No. Hospital Name :
Date of Admission : Date of Discharge :
Policy St. Date : Policy End Date :

Diagnosis :
Settlement Date :

Dear Sir/Madam,

As per the instructions of the insurer The New India Assurance Company Limited, the Claim Number
……………………………...……. for request of INR …………..……./-, is Rejected on the following grounds:
1 Policy coverage for ……………………….. is for ………….Year/Years.
2 Current policy is in ….....……….. Year/Years.
3 Current illness is diagnosed as ___________________________________________________________
4 As per the Policy Conditions, Clause_______, the above condition falls under__________, which states:
“________________________________”
The treatment availed is for the treatment of condition associated with________________, the claim
is not payable

For any further clarifications, you may directly contact the insurer. OR Contact on Toll Free number 1800-209-1415
Thanks & Regards,
Claim Department

Authorised Signatory
This is a computerised statement and hence does not require a signature
For more information please log on to

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 The New India Assurance Co. Ltd.

Our Servicing TPAs

Sr. No TPA party code Name of the TPA Toll Free No.

1 TP00000028 Dedicated Health care Services (India) Ltd 18002090201

2 TP00000008 Heritage Health TPA Pvt. Ltd. 18003453477

3 TP00000003 Medi Assist India TPA Pvt. Ltd. 18004259449

4 TP00000005 MDIndia Healthcare Services TPA Pvt. Ltd. 18002331166

5 TP00000006 Paramount Health Services (TPA) Pvt. Ltd. 1800226655

6 TP00000015 Raksha TPA Pvt Ltd 18004254033

7 TP00000007 E-Meditek (TPA) Services Ltd. 18001023242

8 TP00000013 Family Health Plan(TPA) Limited 18004254033

11 TP00000016 Vidal Health TPA Pvt.Ltd 1800221717,

18004258885,
18004257878

10 TP00000022 Health India TPA Services Pvt. Ltd. 1800220102

11 TP00000012 Medicare TPA Services (I) Pvt. Ltd. 18003453339

12 TP00000024 Vipul Med Corp TPA Pvt. Ltd. 18001027477

13 TP00000023 Good Health Plan Ltd. 18004253232

14 TP00000002 UnitedHealthcare Parekh TPA Pvt. Ltd 1800224646,

18002000000

15 TP00000019 Med Save Health Care TPA Ltd. 1800111142

16 TPA0000035 Ericson TPA Healthcare Pvt. Ltd 1800222034

17 TP00000235 Spurthi Meditech TPA Solutions Pvt. Ltd 18001035757,

18001026161

18 TP00000236 Health Insurance TPA of India Ltd 18001023600

128