The cost of medical treatment has been rising every year and we all, in some way or the other, have been witnesses to it. With this trend showing no signs of slowing down, it is imperative that we buy Health insurance cover to protect our savings. There is a substantial rise in the awareness levels about the importance of health insurance and we can see it in the sales figures of health related insurance products.
However what irritates people and is also a point of contention are the disputes that arise while settling a claim. To keep clear from a dispute, I would suggest that keep the following points in mind and understand your policy better:
Read the policy document carefully
Even the advertisements of the health insurers say so, but how many of us follow it?
You should read all the terms and conditions carefully and be aware of exactly what your policy covers. This would help you avoid any potential disputes. You should know what is covered from day 1, what is covered from day 30 and what diseases have a waiting period. The problem arises when we don’t read these documents and sign them. This leads to a mis-match in what we perceive the policy to cover and what it actually covers.
Acknowledge any pre-existing ailment
When you are buying health insurance cover ensure that you do not hold back any information on any pre-existing illness. It is in your interest that you declare it upfront. Individual policies typically exclude any pre-existing disease at the start of the policy however post a specific waiting period these can be covered in the policy. If you don’t there are chances that when a hospitalisation is required, you would declare these diseases to the doctor before any treatment and if the TPA gets this information at this stage, your claim is bound to get disputed and the chances of it getting rejected become high.
People still tell me why to declare a pre-existing problem, it would unnecessarily complicate things? NO sir, it would on the contrary simplify things when you would actually need the cover.
Know what the exclusions are
Understanding what are the excluded illnesses and the expenses that are not covered by your plan is something that each one of us should be vary of when buying an insurance cover. This is given in the exclusions section, which is there in all the policy documents of all the insurers. Every insurer has a list of illnesses that they either do not cover or there is a waiting period specified for a few of them. There are insurance products that would cover most of the illnesses but then those are going to be expense. Else you can also think of buying a critical illness cover. I will explain about critical illness cover in another post another time.
Scenario: You bought a health cover from an agent who told you that all your medical bills would be cover by the insurance. However, when the claim was to be settled the insurance company did not pay the entire amount. What happens?? You are pissed off but can’t do anything because it is there in the document that you signed.
This clause says that only the expenses that are reasonable and necessary would be reimbursed or settled. This is the way an insurance company protects itself against frivolous claims. Insurance companies compare the value of the bill with standard rates of other hospitals and pays accordingly. So if you have spent Rs.100,000 for a procedure, at a hospital, and the standard rate for the same procedure is Rs.80,000 then the TPA would only sanction a claim of Rs.80,000.
Then there are people who buy two health insurances policies from different companies. This is being foolish. There is no point in taking 2 insurances because when a claim arises and you approach both the companies, they would settle the claim by borrowing funds from both the policies. What we have done, by taking 2 insurances, is that we have spent unnecessary money to get the cover. This is where a good broker comes in. He would give you a suggestion of buying a good top up plan from a good insurer.
Sub-limits, Deductibles and co-payments
There is always a ceiling built in on the expenses one you can incur on different sub headings within the policy. It is imperative that you read this carefully. What you would see is that the insurer has put a cap on things like room rent, OT charges etc. This is despite the fact that you have not exceeded the cover limit. Then there could be clauses that would say that you would have to share a part of the costs that you incurred during your hospitalization. You should also check whether the pre- and post-hospitalisation periods are reimbursed or not. Typically 30 days pre and 60 days post hospitalization expenses are covered.
Cashless treatment at Network hospitals
When you opt for cashless facility, which is the case in 99% of the health covers these days, the procedure is that you should inform the TPA or the insurer about 48 hours before a planned hospitalization (for example, a surgery that you had been planning for some time now). In case of an emergency you should inform the TPA or the insurer within 24 hours after the hospitalization. In case you need to understand the procedure you can always call the TPA or the insurer’s helpline number.
Take control of all the documents
When you are getting discharged from the hospital ensure that you collect all the documents related to your hospitalization. This would include the discharge summary, diagnostic reports, medical advice for the post hospitalization period and copy of the bills and cash receipts that the hospital has generated. When you have all the required documents the claims process becomes much easier and you can avoid any possible delay in the payments, either to you or the hospital.
This will also ensure that in case of any discrepancy that arises at a later stage.