Coverage of boston scleral lense device in medical policy
Nitin
(Querist) 06 August 2014
This query is : Resolved
Dear Sir,
I would like to bring to your kind notice on my case as follow -
I am a eye patient with following disorders as -
1. The power is too High, Left - -28 and Right - -32.
2. Cornea thickness extremely critical, Left - 160 and Right - 250.
3. Retina Detachment in Left Eye 2013 treated by Buckling surgery.
4. keratoconus at extreme in both eyes.
5. Extreme dryness with very low vision clarity due to extreme keratoconus.
6. Using normal B & L Lenses from last 12 years for vision.
7. Power No. in glasses not possible beyond -24 and in normal contact lenses beyond -21.
I am a regular patient at Snakara Netralya Chennai from last few months and a patient of Dr. Prema Pedmanabhan (H.O.D Cornea, Medical Director SN).
As far doctor advice I have to go for cornea transplant or for boston scleral lenses device.
I want to avoid cornea transplant because of following complication as far as my case is concerned -
1. The transplant has to be done until the body accept cornea, may be onse or repeated as required.
2. Retina Detachment can be repeated in both eyes.
3. Glaucoma can be a disease because of surgery in future.
4. Cataract development can be a disease because of surgery in future.
Apart from these all any other major issue can arise as far doctor opinion.
So I decided to go for other option of BOSP Lenses and had a detailed trail in hospital with success.
I had placed a order for lenses and would receive them on 17-08-2014 in my coming visit.
I had a medical family policy running from last 4 years with a cover of 700000.
In Normal cases contact lenses are not covered but since I am suffering from multiple disorders and these lenses are necessary as a part of treatment of keratoconus and also to prevent cornea from further detonation and to maintain a better health of cornea.
In my case C3R or any other surgery for keratoconus is not possible because of low thickness of cornea and perhaps this BOSP is only solution apart from transplant in both eyes.
So in my case I would like to take all experts opinion that are these lenses can be reimbursed in my case or not.
Please reply early as I am short of time.
Kumar Doab
(Expert) 06 August 2014
Has the panel of experts has rendered the advice for implant of lenses in writing under proper seal and signature?
Usually when intimation of claim is sent to Insurance Company/TPA the Company/TPA issues approval/declinature.
You can submit the intimation for said procedure and ask for comments.
Since you have placed the order for lens, it is time to put all docs in order and build record.
A lawyer handling consumer/such/medico-legal cases can advise you the best after examining all docs on record.
Nitin
(Querist) 06 August 2014
Dear Kumar,
Can you please let me know the details of document i need to submit TPA, as at moment i don't have any and doctors will send them on email / post after handing over the lenses.
They have entire record in there e system and dont handover it to patient directly, rather prefer to post or send on email later after consultation.
The hospital is on panel of RAKSHA TPA and I am on it with policy from Oriental Insurance.
Kumar Doab
(Expert) 06 August 2014
The hospital/doctor should supply the detailed opinion for need of lenses on your hospital card and you can ask for seal and signature of the doctor.
It is strange that the doctor/hospital shall not supply the expert opinion that forms basis for requirement of implant till the lens to be implanted is handed over to them!
Your lawyer may opine that you should cover such points in writing.
You have also downloaded the narrative that you have posted in your query from some document that is in your record.
M/s Raksha TPA/Oriental Insurance can ask for the documents in response to your post to them.
Accordingly you can ask for the details/documents from doctor/hospital.
Get in touch with all parties, and more importantly your lawyer.
Rajendra K Goyal
(Expert) 06 August 2014
Consult a local lawyer dealing in medical insurance claim cases and show him all the documents.
Nitin
(Querist) 07 August 2014
Still waiting for experts from medical / TPA field
Devajyoti Barman
(Expert) 08 August 2014
get satisfied with what you have got so far.
