Things you should know while seeking your Health Insurance claim
Many policyholders have faced difficulty in seeking claims from the insurance company during the second Covid19 wave. This has resulted not only in a lot of frustration but also financial disruption among families as the bills for treatment ran in lakhs. This has highlighted very important facts that claims have to be dealt with utmost care and the following important aspects need to be borne in mind while seeking a claim;
1) Terms of the policy-The policyholder who is seeking the claim should have clarity of the terms of the policy. Many a time the deductions are being made as per the limits prescribed in the policy. These limits and conditions are in the form of room rent capping, limits prescribed for listed diseases, consumable charges deductions, and many more. All such conditions in a policy lead to a partial payment of the claim which further leads to disappointment/disputes with the insurance company as the terms of the policy is not understood at the time of buying a policy.
2) Misrepresentation at the time of buying a policy- Many times the policyholders do not disclose the pre-existing diseases at the time of buying the policy. It is a pre-condition laid down by the insurance company that any wrong declaration can lead to denial of the claim. However, neither the policy proposer nor the intermediary takes the disclosure of the facts regarding the health conditions seriously at the time of filling up the form. It is only at the time of hospitalization when the claim is being forwarded for approval, the facts get highlighted to the TPA through doctors of the hospital and any concealment of facts leads to rejection of claims.
3) Rejected claim with some merit should be represented- The claim that gets rejected/partially paid should be represented with facts and supportive documents. The insurance company many times are not able to approve based on the initial information given by the policyholders. No insurance company can process the claim without getting the right information supported by the reports and necessary documents. For example, a treating doctor wrongly declares his patient as diabetic due to which the claim will certainly get rejected for the reason of misrepresentation. However, the same can be represented by the policyholder to the insurance company for the review with the support of the right documentation and clarification by the treating doctor to establish the genuineness of the claims.
Moreover, a policyholder is entitled to following claims beyond hospitalisation claim;
Pre and post hospitalization Expenses- Every policyholder can claim expenses incurred 30 days prior to hospitalization and 60 - 180 days post hospitalisation depending on terms of the policy. This indeed is a benefit that is part of the policy and one can claim up to the limit of Sum Assured i.e. SA- hospitalisation bill= Available SA for expenses in pre and post hospitalisation. Many times the policyholders aren’t aware of such benefits and miss claiming within the stipulated time. Therefore, one should use this benefit within 30 days from the maximum permissible days after hospitalisation.
Annual health benefits- This feature isn’t well known to most of the policy holders who have bought new generation plans. One can claim annually up to a limit linked to SA against the medical test and health check-up. The bills along with the claim form have to be submitted or many companies have facilitated uploading the claim bills in their app to get the same settled.
It is a wrong belief that the claims are not paid by the insurance company rather it is the claims that get into dispute for reasons ranging from undisclosed facts to compromised policy terms to misrepresentation of facts and many more. The policy needs to be understood well before the claim is lodged and it is more of handling of queries of TPA /claim department of Insurance Company for smooth settlement of the same. It is advisable for the claimant to involve their broker or agent or advisor from whom the policy was bought to seek assistance before the filling of claim to understand the aspects that need to be factored in.