This is my 120th original content in 2022.
The dispute over the diagnosis of malignant thyroid tumor can be said to be the most magical thing I have ever seen.
Claim settlement depends on treatment methods, pathology reports, genetic testing and discharge medical records, and the hospital's diagnosis conclusion can determine whether the final claim is settled!
Hundreds of thousands of insurance benefits will be denied just because of ambiguous words such as "suspected diagnosis" and "not ruled out" in medical records, and such disputes are not uncommon.
Let’s talk with you in detail about the diagnosis of malignant thyroid tumors.
In December 2017, Zhang purchased Taiping Life Insurance 's Lexiang Wuyou Lifelong Critical Illness Insurance, with an insured amount of RMB 100,000.
The terms stipulate that [malignant tumor] refers to
"a disease in which malignant cells grow and spread uncontrollably, infiltrate and destroy surrounding normal tissues, and can spread and transfer to other parts of the body through blood vessels, lymphatic vessels and body cavities. The diagnosis is confirmed by pathological examination results, clinical diagnosis belongs to World Health Organization "Diseases and Related Health Problems" International Statistical Classification of Malignant Tumors (ICD-10). "
In August 2021, Zhang was admitted to the hospital for examination. The result of his fine needle aspiration cytology examination was "a few atypical cells were found, excluding papillary thyroid carcinoma. Please combine it with clinical practice. " But he did not agree to the operation and asked to be discharged from the hospital. He was diagnosed with a malignant thyroid tumor.
The insurance company refused to compensate because did not meet the claim conditions of the insurance contract.
Let’s first talk about what the [malignant tumor] claim conditions agreed in the insurance contract are - Generally, there are three conditions for claims settlement of malignant tumors: one soft condition and two hard conditions:
First, there are descriptions of cancer cells such as "infiltration" and "spread" in the pathology report or medical record, and the word "non-invasive" may cause claims disputes.
Second, the pathological examination results must be clearly diagnosed as malignant tumors. Any non-clear diagnosis descriptions such as "suspected" and "not ruled out" can easily lead to claims disputes.
Third, the main diagnosed disease in the discharge medical record and the first page of the medical record must be malignant tumor, and the disease code must start with C, otherwise the claim will be directly rejected.
Let’s look at this claim dispute again. Zhang’s cytopathology report stated that “papillary thyroid cancer is not excluded” and there was no clear diagnosis.
Moreover, Zhang did not receive surgical treatment. This was actually a concept of insurance protection. Therefore, the insurance company believed that Zhang had not been diagnosed clearly and therefore refused to pay the insurance benefits.
But even if Zhang did not undergo surgical treatment, the hospital diagnosed his disease as a malignant thyroid tumor based on the pathology report and other examinations, so the insurance company would naturally have to pay compensation!
It is no exaggeration to say that the hospital’s discharge diagnosis can determine whether to settle a claim!
In fact, the claim settlement for malignant thyroid tumors is very magical.
(1) As long as the pathology report clearly confirms the diagnosis of malignant tumors, there will basically be no major problems in the discharge medical record, and the claim settlement will be very smooth.
(2) As long as the pathology report does not clearly confirm the diagnosis, the insurance company can find fault and not compensate!
(3) The worst thing is the third type. Not only is the pathology report not clearly diagnosed, but the discharge medical record also says " thyroid sarcoidosis " or "thyroid tumor". In this case, even if there is a thyroid cancer-related gene V600E mutation, it will be very difficult to settle claims!
The doctor's identification of the disease can almost determine whether to settle a claim, and different hospitals are likely to have completely different diagnostic results...
Everyone must communicate with the doctor when seeking medical treatment to let them clearly diagnose a malignant tumor within their authority, otherwise it will be very troublesome to settle claims after discharge!
or above, the specific situation will be analyzed in detail, and you can leave a message if you have any questions about claims.
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