Vinod Sharma · Phacoemulsification with monofocal IOL — right eye
Ophthalmologist notes show reduced visual acuity, glare while driving at night, and slit-lamp findings consistent with age-related nuclear cataract in the right eye.
- 1Cataract diagnosis is clinically consistent
Ophthalmologist notes show reduced visual acuity, glare while driving at night, and slit-lamp findings consistent with age-related nuclear cataract in the right eye.
94% - 2Day-care eligibility is clean
Fortis Memorial is a cashless network hospital, cataract with IOL is a listed day-care procedure, and the waiting period is satisfied.
95% - 3Cataract sub-limit caps approval
Policy pays up to ₹40,000 per eye for cataract. The quoted package is ₹60,000, so the family should expect roughly ₹20,000 at discharge.
91% - 4Lens upgrade must remain transparent
Base monofocal IOL is admissible within the package. Multifocal or toric premium lens upgrade, if selected, is payable by the family beyond the cataract cap.
88%
- Visual acuity: right eye 6/24, improves poorly with refraction.
- Slit-lamp: nuclear sclerosis grade III, right eye.
- No diabetic retinopathy noted.
- Monofocal IOL package selected; premium lens upgrade discussed separately.
“Cataract surgery with intraocular lens is covered as a day-care procedure subject to the per-eye sub-limit stated in the policy schedule.”
“The maximum payable for cataract treatment is ₹40,000 per eye, inclusive of surgery, standard IOL, OT, medicines and day-care charges.”
“Items such as admission kits, attendant charges, registration fees and certain consumables are not payable under standard indemnity.”
- Policy active on date of admissionPASS
Policy PRU-FF-2025-008821 active 2025-04-01 → 2026-03-31.
Ref: Policy schedule, Sec 1 - Member covered under policyPASS
Vinod Sharma is listed as father on Rohan's family floater. UHID match verified.
- Initial 30-day waiting periodPASS
Policy inception 2025-04-01; admission > 30 days later.
Ref: Policy wording Cl. 4.1 - Specific-disease 24-month waiting — cataractPASS
Cataract is subject to a 24-month waiting period. Continuous cover is satisfied through senior-care add-on underwriting and declared eye history.
Ref: Policy wording Cl. 4.2(d) - Pre-existing disease (PED) checkPASS
No prior cataract surgery or eye trauma declared. Age-related cataract was first documented at this OPD consult.
Ref: Proposal form Sec 6
- Hospital in network (cashless enabled)PASS
Fortis Memorial Research Institute — Network hospital, NABH + JCI accredited.
- Day-care procedure admissiblePASS
Cataract surgery with IOL is a listed day-care procedure and does not require 24-hour admission.
Ref: Policy wording Cl. 3.2(d) - Procedure admissible under IP benefitsPASS
Phacoemulsification with monofocal IOL (ICD-10 H25.11) is a listed cataract day-care benefit.
- Cataract sub-limitWARN
Policy caps cataract at ₹40,000 per eye. Hospital estimate is ₹60,000, so ₹20,000 remains payable by the family unless package is reduced.
Ref: Policy wording Cl. 3.2(d) - Estimate within sum insured availablePASS
Estimate ₹60,000 vs. cataract sub-limit ₹40,000 per eye. Available floater SI remains adequate.
- Fraud / abuse signalsPASS
No duplicate-claim signal. No provider outlier billing. Member's claim velocity nominal (1st claim in 22-month history).
| Code | Description | Category | Qty | Unit | Total |
|---|---|---|---|---|---|
| DAYCARE-BED | Day-care recovery bed and nursing | ROOM | 1 | ₹6,000 | ₹6,000 |
| SUR-PHACO | Phacoemulsification cataract surgery — surgeon fee | SURGERY | 1 | ₹22,000 | ₹22,000 |
| IOL-MONO | Monofocal intraocular lens package | CONSUMABLE | 1 | ₹12,000 | ₹12,000 |
| OT-EYE | Ophthalmic OT and microscope charges | OT | 1 | ₹9,000 | ₹9,000 |
| ANES-TOP | Topical anesthesia and monitoring | ANESTHESIA | 1 | ₹3,000 | ₹3,000 |
| INV-EYE | Visual acuity, slit-lamp and biometry workup | INVESTIGATION | 1 | ₹4,000 | ₹4,000 |
| DRG-EYE | Eye drops and post-op medicines | DRUGS | 1 | ₹2,000 | ₹2,000 |
| MISC-REG | Registration and admission kit | MISC | 1 | ₹2,000 | ₹2,000 |
| Total billed | ₹60,000 | ||||