A recent Economic Times online survey shows that almost 60% of the people who filed claims were dissatisfied with their experience.
So in this article, I decided to look at health insurance claims in greater depth, focusing on the areas where maximum claim related conflicts occur and what you can do to extract the maximum value from your policy during claims and come out of the experience truly satisfied.
One of the biggest reasons for dissatisfaction with claims is a lack of awareness of the policy terms and conditions.
It can’t be stressed enough that every policyholder should read one’s policy document as soon as you receive it. If any terms and conditions are not clear, you should call us up your insurer to understand it better.
Top 4 Things To Be Careful with Health Insurance Claim
Let’s understand the top conditions that you have to be careful of :–
Most health insurance policies require the patient to be admitted for a minimum of 24 hours or more to avail of the benefits. This is a firm rule but excludes a few daycare procedures, which will be mentioned in your policy document. So if you were to go to your hospital fora tetanus shot, for example – you won’t be able to file a claim on that basis.
Your policy will have limits of certain procedures like the maximum price of the room that you can avail of. Now you might want to go for a higher-priced room, and you’ll assume that you can pay the difference between the actual rent of the room and the allowable limit. Pls, don’t do that.
Contact your insurance company before you do something like this because insurers often treat room up-gradation as a partially payable claim. In other words, never decide to alter the terms of your insurance contract unilaterally.
The third area, you need to pay attention to your waiting period on specific diseases. The waiting period is a sort of a hibernation period during which any claims made will not be admissible. A good number of consumers are unaware that claims for certain conditions are inadmissible for up to two years.
While these are a handful of conditions but it includes popular ones like tonsils, hernia, cataract, etc. A list of these medical conditions will be available in your policy wordings.
And finally, there is a waiting period on pre-existing conditions where there is a wait of 3 to 4 years.
This is another clause that several policyholders are not aware of because they did not read the policy document and leads to dissatisfaction when they apply for claims within the waiting period for pre-existing ailments.
A common problem related to this is that consumers don’t state their pre-existing condition while taking the policy.
This generally happens when consumers allow agents to fill the proposal form on their behalf or when they take the application process very light, and omit these details accidentally or on purpose.
This is a tough situation for the policyholder and the insurer, but because every insurance contract is agreed on the basis of good faith – there is every probability that the claim will not be admissible in case the declaration made by the policyholder is false or partial.
The fourth area and the last of the key clauses that have a significant impact of the claims are limiting conditions like co-payments, sub-limits, and exclusions. Co-payments are where you will pay part of the claim, and the insurer will pay part of the claim.
If you have ever made a car insurance claim without having zero depreciation on your car insurance policy, you would have noticed that you had to pay like 30-35% of the total bill to the workshop, and the insurance company paid the rest.
Similarly, co-payment may be triggered in your health insurance contract in some situations, which is why you should read the policy document carefully once you receive it.
The same is true for sub-limits, which by definition, mean that the insurance contract has a capping on how much is payable for a particular illness.
I have commonly seen sub-limits used for procedures like cataract, total knee cap replacement, and kidney dialysis.
These, too, will be in your policy document and will go something like Rs. 20,000 per eye for cataract removal. And finally, the exclusions.
This is one part that I can’t stress enough on and becomes the cause of a lot of hardship.
Most health insurance policies don’t cover maternity and childbirth, yet a huge number of claims are lodged toward these due to a lack of awareness of policy exclusions.
Other exclusions in the policy include participation in adventurous activities, abuse of intoxicants like alcohol, mental disorder-related ailments, etc.
There are some smaller payments which are generally not included payable. Again, most policyholders assume that these expenses are claimable, but that is not the case.
Some expenses which get omitted in the payable claim include registration & discharge charges, cost of hearing aid, any toiletries, donor screening charges, etc.
Understanding co-payments, sub-limits, and exclusions is a must to ensure you are claiming the right procedures as contracted under your health insurance contract.
The secret to a happy claims experience is to have a clear understanding of what is claimable and what is not under the terms of your policy, most of which are available in the policy wordings.
This includes inclusions, exclusions, waiting periods, sub-limits, etc. If you are thorough in your research, you wouldn’t have to worry about claim rejection.
And when you know what is in your policy, it also gives you the necessary knowledge 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 comment in the comments section below or call your insurance company for better clarification.
If you liked this article, share it with your friends, and don’t forget to check out the health insurance section on the ETMONEY app for more information on everything we have discussed in this article. Thank you for reading this article.