DENTAL SURGERY IN DENTAL CLINIC AS DAY CARE PATIENT- INSURANCE COVER UNDER IBA GROUP POLICY FOR RETIREES
Large number of bank retirees are having doubt if dental surgery/treatment performed / taken in a private dental clinic [not hospital] under day care is covered by IBA Group Insurance Policy or not. In most of cases such claims are denied by TPA/Insurance Co as treatment is not taken in a hospital. My humble opinion is that such claims are payable even if treatment/surgery is taken/performed in a private dental clinic, subject to following conditions, based on clauses 2.9, 2.10 and 3.3 of insurance policy:
01. Treatment /surgery should be administered/performed by a qualified and registered doctor [say BDS/MDS etc]
02 Clinic should be registered with local municipal authorities, wherever it is legally required to register.
03. It could be a department of a registered hospital rather than stand alone facility/unit.
04. It should have qualified nurses.
05. In-charge of Unit should be qualified in dentistry [say BDS/MDS].
06. Unit should have fully equipped operation theatre of its own where surgical procedure is carried out.
07. Unit should maintain daily record of patients which should be made accessible to Insurance Co staff.
08. Medical treatment and surgical procedures are covered.
09. Treatment/procedure should be done with local or general anesthesia.
10. Treatment/procedure should be done in a dental clinic or day care centre. Dental clinics are treated as day care centre in my opinion.
11. Treatment/procedure may require less than 24 hours due to technological advancements in medical treatment of diseases. Hence visits for treatment/procedure for few hours per day on various different days should be covered.
12. But for technological advancements, the treatment/procedure/surgery would have required hospitalization of more than a day.
13. Treatment taken as OPD patient will not generally be covered.
14. List of treatment/procedure at clause No. 7 of insurance policy covers dental surgery.
15. It is advisable to obtain attached certificate along with Form-B of claim form, self attested photocopy of treating doctor’s final degree certificate and municipal registration license of day care centre/clinic, whenever dental treatment is taken in a private dental clinic as day care patient.
[Compiled for guidance of bank retirees by J P Shah, RTI & Consumer Activist]
Blog: www.jps50.blogspot.in 12022018
Format of certificate…………….
This is to certify that following patient has undergone dental treatment/surgical procedure in this clinic /day care centre for his dental disease:
Name of patient: Gender & Age of patient:
Address of patient: Patient No:
Particulars of disease:
Details of treatment /procedure:
Period of treatment / procedure:
Dates of visits to dental clinic/centre Arrival Time Period [in hours]
Total amount charged as per details in bill: Rs.__________
Treatment / procedure was administered/performed by a doctor qualified in dentistry, assisted by qualified nurses, under local anesthesia. He was day care patient for this day care centre/clinic and NOT out door patient. This centre/clinic is registered with municipal authorities.
Rubber stamp: SIGNATURE OF TREATING DOCTOR
Countersign: Registration No:
In-charge Doctor of day care centre / clinic [if not treating doctor]