Read the claim settlement process in the policy document carefully so that you should not miss anything from your side on which grounds the insurer may find reasons to disregard the claim or deduct any payable amounts. Our team has compiled a list of some of the common reasons for which you might face difficulties in claiming under your health insurance policy
It is a standard policy of all insurers to intimate them about the claim, within 24 hours of hospitalization even during emergency. In case of planned treatment, the insured has to inform the insurer at least 4 days before treatment.
Several insurance companies began rejecting claims when they had been submitted late, and most of them began deducting 10% from the claims amount.
Irdai has strongly criticized the insurers in this case. A circular recently issued by the regulator advised all insurers to refrain from rejecting claims due to late submissions, unless the claim was intentionally delayed to attempt to misrepresent the facts.
“A material fact under the insurance contract is -any situation or information which can increase the frequency and/or severity of loss which is covered under that particular insurance contract.”
A dog bite could be a material fact for a health insurance contract which has to be declared by the proposer to the insurance company. But this is not a material fact in the case of buying home insurance.
Secondly, just a declaration of fact is not enough to satisfy the condition of material fact. It is also important to be accurate and complete.
In short, any miss-representation or non-disclosure of even a part of the information is considered a violation of the material fact clause.
It’s always advisable to take the help of insurance brokers to avoid anything which could disqualify your claim in the future. The good part is, it will not cost you anything.
How many of you have read about Modern Treatment Methods and Advancement in Medical Technologies?
Whenever you take any Mediclaim or Health Insurance policy, check if the above is covered or not. Most of us are taking health insurance for the future and this technology will be common in the coming days.
Reasonable and customary charges is one of the most dreadful clauses in Health Insurance.
The terms reasonable, usual and customary refer to the average claim paid by your Insurance Company for a particular ailment.
A charge is considered reasonable, usual and customary if it matches the general prevailing cost of that service within your geographic area, which is calculated by your insurance company.
The insurance company then uses this information to determine how much it’s willing to pay for a given service in your area.
This means that if your hospital charges above the reasonable and customary charge, you may have to pay the remainder.
This clause gives a lot of room for an insurance company to cut down the claim amount and in fact it is the most disputable clause in the whole policy document.
Apart from room rent all the other items as listed above under hospitalization expenses are dependent on how the room rent is being charged at the hospital. This feature has a great impact on the overall claim amount payable under health insurance.
Insurance companies put a sub-limit (Capping) on the room rent payable under a health insurance policy in case of hospitalization.
If you opt for a room rent crossing the limit mentioned in the policy, along with excess rent, the insurance company will deduct the cost of other services like doctor’s fees, surgery charges, etc. Proportionate to the room rent charges.
This is because, in any hospital, the cost of exactly the same set of services is charged differently for different room types. The hospitals charge low cost for rooms with lower rent and high cost for rooms with higher rent.
Charges which are based on MRP (like medicines) are charged the same for all types of rooms. Hence, these charges will have no impact on room rent capping. Hence it is better to opt for the policy which defines the room rent as “Standard Private AC Room”
In general, adding and deleting members in a group policy happens on a pro-rata basis. However, some insurers have recently started making additions and deletions on a short-term basis. In the next 365 days, if you have a high attrition rate or you are growing as an organization, it can have a significant impact on your overall premium.
Some insurers allow the possibility of porting the benefits to a retail policy when the employee resigns. This will enable him not to lose the continuity benefits when he shifts to an individual plan. Check these conditions before you sign up for the policy.
The claim might be rejected if the insured conceived for the third time but was unable to deliver during any of her previous pregnancies. In this case, it is better to ask insurers to change the condition to "Maternity is covered for the first two children."
When possible, choose the cashless mode of claiming. Do not share the exact amount insured with the hospital, rather ask for the standard fees. This may lead them to inflate the claim amount or overtreat.
It is possible to combine two or more policies to increase the sum insured or to claim deductions under the copayment or room rent clause. It will be necessary for you to request your original documents from the primary insurer and submit them (along with settlement details from the primary insurer) to the secondary insurer as reimbursement claims.
Insured should always make a file of all medical expenses and reports in a sequence. This you need to submit to TPA or Insurer’s Inhouse settlement team for verification and calculation of the payable amount.
As part of the policy placement process, Ethika takes care of all these conditions.
Claim is admissible only when the Insured gets admitted in hospital for a minimum of 24 hours. With the advancement in Science and Technology, there are certain surgeries which do not require 24 hours hospitalization. They take more than 2 hours,and are also expensive. This is where a compulsory 24 hours hospitalization clause needed relaxation to include such expenses. Because this was causing moral hazard as insured and the hospital with mutual understanding extended hospitalization to 24 hours to get coverage. Either in real time or just in papers.
Insurers have listed around many such treatments called “Day care procedures” where and allow medical coverage even if 24 hours minimum hospitalization is not given. Even if it is not listed, you can request them to include it and take approval before going for admission.
Don’t get confused between day care procedures and outpatient expenses. No insurance company pays for the stand alone Outpatient treatments like POP because of bone fracture, stitches with local anesthesia, doctor consultations, health tests etc.,
There are more than 580 Day Care procedures. The number of such Day Care procedures being covered differs from insurer to insurer.
Imagine that I get chest pain at night, and I go to an emergency ward in hospital because I think it could be a heart attack.
I was immediately admitted and underwent a series of diagnostic tests for the next 24 hours.
The report indicates that the chest pain was caused by a gastric problem, and no treatment was required. While I am glad that nothing bad happened to me, I will be disappointed that my insurance claim will be rejected due to the clause “no inline treatment was provided”.