Dad admitted to ER for acute breathlessness and diagnosed with H1N1 Pneumonia. TPA/Insurance manager threatening rejection because "chronic smoker" is on ER case sheet. Need advice.
Hi everyone,
My dad was rushed to the ER for acute breathlessness and severe respiratory distress. The initial medical finding was acute pneumonia. Later, his RT-PCR test confirmed H1N1 Viral Pneumonia. Doctors are also currently evaluating a secondary suspicion of ILD (chest CT is pending).
When he was brought into the ER, my dad honestly mentioned to the triage doctors that he is a chronic smoker, and the doctors wrote "chronic smoker" in the initial case sheet history.
Here is where the issue begins:
Policy History: This is the 9th continuous year of his health insurance policy. However, he had not declared himself as a smoker when the policy was initially taken 8+ years ago.
The Agent/Insurance Manager Stance: The insurance manager/agent is warning us that any case mentioning "smoking" gets straight-away denied. They claimed the company will reject the claim, tag him as a smoker in their records, and use it to deny all future claims too.
Hospital TPA Stance: The hospital TPA sent the ER case sheets (including the smoking note) to the insurance company for pre-auth. They are refusing to guarantee cashless pre-authorization, advising us that we may need to pay cash upfront and apply for reimbursement later.
From what I understand, an emergency ER admission for acute H1N1 viral pneumonia shouldn't be rejected just because a patient smokes, especially since this policy is in its 9th year and should be protected under IRDAI’s Moratorium Period rule (which bars non-disclosure rejections after 5 to 8 continuous years).
Despite this, the threats from the agent and the TPA's hesitation are making our family really anxious while my dad is still in the hospital.
I would really appreciate advice on:
Has anyone faced a pre-auth rejection due to "smoking notes" written by ER doctors for an acute viral/infectious illness?
How strongly does the IRDAI Moratorium Period hold up if the insurer tries to issue a non-disclosure query?
If cashless pre-auth gets denied and we have to go the reimbursement route, what specific steps/doctor notes should I collect before discharge to make sure our reimbursement file doesn't get stuck?
Thanks in advance for your help!