Health insurance claim process
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A recent Economic Times online survey shows that nearly 60% of those who filed claims were dissatisfied with their experience.
That’s why in this post we decided to take a more in-depth look at health insurance claims with a focus on the areas where maximum claim conflicts occur and what you can do to get the most out of your policy when it comes to claims and Really satisfied can come out of the experience.
Before we start, make sure you share this post on insurancekesele.com with all friends and family so that they can be of help.
One of the biggest reasons for dissatisfaction with claims is the lack of awareness about the terms and conditions of the policy. It cannot be stressed enough that every policyholder should read your policy document as soon as he/she receives it and if any terms and conditions are not clear, then contact us at INSURANCEKESELE.COM or your insurer to understand more about the same should call.
Let us understand the top situations that you have to beware of –
1. Most health insurance policies require the patient to be admitted for at least 24 hours or more to receive benefits.
This is a firm rule, but does not cover certain daycare procedures that will be explicitly mentioned in your policy document. For example, if you go to your hospital for a tetanus shot – you will not be able to file a claim on that basis.
2. Your policy will have limits on certain procedures such as the maximum room price that you can avail. Now you may want to go for a higher priced room and you will assume that you can pay the difference between the actual rent of the room and the allowable limit. Please do not do this. Check with your insurance company before doing anything like this as insurers often treat room upgrades as a partially payable claim. In other words, never decide to unilaterally change the terms of your insurance contract.
3. The third area you need to pay attention to is your waiting period on certain diseases Waiting period is a kind of hibernation period during which any claim made will not be accepted. A good number of consumers are not aware that claims for certain conditions are inadmissible for up to two years. Although these are just a few conditions, they include popular conditions like tonsils, hernias, cataracts, etc. A list of these medical conditions will be available in the wording of your policy.
And finally there is a waiting period on pre-existing conditions where there is a waiting period of 3 to 4 years. This is another clause that many policyholders are not aware of as they have not read the policy document and become dissatisfied when they apply for claims within the waiting period for pre-existing diseases. A common problem associated with this is that consumers do not disclose their pre-existing condition at the time of taking the policy. This usually happens when consumers allow agents to fill out proposal forms on their behalf or when they take the application process too lightly and omit these details accidentally or on purpose.
This is a very difficult situation for the policyholder and the insurer, but because every insurance contract is agreed upon in good faith – there is every possibility that the claim will not be admissible if the declaration made by the policyholder is false or partial.
4. The fourth area and the last major clause that have a major impact on claims are limiting conditions such as co-payment, sub-limit and exclusion.
Co-pays are those where you will pay part of the claim and the insurer will pay part of the claim.
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If you have ever claimed car insurance without zero depreciation on your car insurance policy, you must have noticed that you have to pay 30-35% of the total bill at the workshop and the insurance company has paid the rest.
Similarly, in some situations your health insurance contract may introduce co-pays, so once received you should read the policy document carefully. The same is true for sub-limits, meaning there is a capping on how much is payable for a particular illness in the insurance contract. I have seen subscales commonly used for procedures like Cataract, Total Knee Can Kidney Dialysis. These will also be there in your policy document and Rs. 20,000 per eye for cataract removal
And lastly, exclusions This is a part I cannot stress enough on and causes a lot of difficulty. Most health insurance policies do not cover motherhood and childbirth, yet a large number of claims are filed for these due to lack of awareness of policy exclusions. Other exclusions in the policy include participation in adventure activities, substance abuse such as alcohol, illnesses related to mental disorders, etc.
There are some small payments that are not usually due. Again, most policyholders assume that these expenses are claimable but are not. Some expenses that are omitted in the payable claim include registration and discharge fees, cost of hearing aids, any toiletries, donor screening fees, etc. Understanding co-pays, sub-limits and exclusions is essential to ensure that you are claiming for the correct procedures. As stipulated under your health insurance contract.
The secret to a happy claims experience is having a clear understanding of what is and what is not claimable under the terms of your policy, most of which are available in policy words.
This includes inclusions, exclusions, waiting periods, sub-limits, etc. If you’re thorough in your research, you won’t need to worry about claim rejection. And while you know what’s in your policy, it also gives you the knowledge you need to fight for any unjust calls made by the insurer’s claims team.
And if you have any doubts about anything in your policy, feel free to contact the insurance company or the team at your insurance company for better clarification
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