Understanding query: Kindly justify the need for hospitalization in this case. Why it cannot be managed on OPD basis?

Query Description

Kindly justify the need for hospitalization in this case. Why can't it be managed on an OPD basis?

Meaning of Query

None of the insurance policies pay for hospital admission when it is done only for the purpose of diagnosis. In some cases, either the doctor admits the patient without real need for admission, or the patient asks to be admitted and gets the doctor to comply. However, at times, conditions such as fever, headaches, vomiting, stomach pain, etc. which can get severe necessitating hospitalization for stabilizing the patient.

If the claimant has received this query, it means the treatment given to the patient is ambiguous and therefore the insurance company wants to be sure there was really a need for hospitalization.

Query Resolution

This query must be replied to by the treating doctor. He or she must write a clarification letter specifying in their letter 3 things:

• What was the condition of the patient which required hospital admission? They can add readings of vitals and other investigation reports to support their observation.
• What was the course of treatment given at the hospital?
• What was the condition of the patient at discharge time?

While all of this may have been mentioned in the discharge summary itself, the insurance company will still insist on a letter from the treating doctor and they may have to repeat the same information in their clarification letter.