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 and if any terms and conditions are not clear, your insurer to understand more about it.
Let’s understand the top conditions that you have to be careful of – 1. 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 clearly 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.
2. 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 simply 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 another word, never decide to alter the terms of your insurance contract unilaterally.
3. The third area you need to pay attention to is to your waiting period for certain 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 not aware 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 a number of 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 make the application process very lightly & 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 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.
4. The fourth area and the last of the key clauses that have a major impact on 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 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. There are some smaller payments that 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 are a must to ensure you are claiming for the right procedures as contracted under your health insurance contract.
The secret to a happy claims experience is to has a clear understanding of what is claimable and what is not under the terms of your policy most of which is 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, then it also gives you the necessary knowledge to fight for any unjust calls made by the insurer’s claims team.