Hello Readers!
The second wave of COVID-19 hit hard, which resulted in several people getting hospitalized for one or other reasons. Similarly, several health insurance policies were claimed during the pandemic, but as a conventional, the process of claiming was tiring for many of them!
People on one side were dealing with an unwell or injured family member while on the other side they were getting frustrated due to process inefficiencies, endless paperwork, and claim delays. At the same time, they were worried and unsure about which of their expenses would be covered under the policy and which will be left to cover from their pocket.
Such disputes in the claims process can make it all the more frustrating for you, adding agony to an already unpleasant situation. But what can you do?
Well, in such scenarios, what only helps is educating more and more yourself about the policies terms and conditions and what facility does it provide. Make yourself aware of such kinds of disputes that arise while claiming the policy in advance, so that you can prepare yourself better to deal with such situations.
Let us know about such common disputes that arise while claiming your health insurance policy, and how an individual can prepare themselves for such situations.
Only Necessary Hospitalizations Are Covered…
This point in a health insurance policy terms and conditions is much necessary to be understood clearly to the policyholder. This point actually means that a health insurance policy only covers hospitalization expenses that are ‘Medically Necessary’, which means:
- The individual must be admitted to the hospital for medical treatment.
- The treatment undergoing must involve a necessary level of care, intensity, and duration.
- The treatment is either prescribed by a medical practitioner or by a doctor who is in any terms not related to the patient.
- The treatment conforms to accepted professional standards, medical practice internationally, or in India.
While you claim your health insurance policy, ensure that the above-mentioned conditions are fulfilled. In case any of the conditions remain unexplained, your policy claim might get rejected because the hospitalization was not ‘medically necessary.
While you get yourself admitted to the hospital on the recommendation of a doctor, do not forget to take the recommendation in writing from the doctor, only after that get hospitalized for further treatment.
Treatment Must Be Active…
People get admitted to hospitals for many reasons and not only for medical or necessary treatments. But to be eligible for the health insurance cover, the patient must get an ‘active line of treatment’ while being admitted to the hospital.
An active line of treatment basically means the patient admitted to the hospital is receiving any necessary medical treatment, and he/she is not admitted to the hospital for purpose of observation, diagnostic tests, or monitoring.
Many people got admitted to hospitals as soon as they got COVID positive, only to quarantine. In case COVID patients admitted to hospitals do not undergo any active treatment, such claims will not be paid by the insurer.
What do you need to do? You need to make sure that the reason for getting hospitalized is genuine and includes an active treatment. If you’re worried about a condition and want to get hospitalized just for monitoring (say pain in the chest or breathlessness), and are sent home without treatment, prepare to pay for the admission yourself.
If You Miss Any Detail In The Proposal Form…
At the time of filling the proposal form for health insurance, it is asked to the policyholder to give personal details and medical declarations, as, based on these documents, the insurer approves your health insurance policy. In the case at the time of claiming the policy, if the insurer finds that the information you provided is not accurate or complete, it will have the right to deny your claim. In fact, it can also cancel your health insurance policy on the ground of misrepresentation.
Thus, make sure that you declare all the medical conditions at the time of the proposal of the health insurance policy. In case if you develop any other medical condition during the policy tenure, get it updated to the insurer as soon as possible. You can also declare it at the time of renewal of eth policy.
Room-Rent Limits…
Most of the health insurance policies include a limit on the room-rent amount, usually 1-2 percent of your total sum insured per day. In case you get a room that of higher cost than the limit, then you will end up with a heavy bill to be paid from your pocket.
How to calculate it?
You can calculate the hefty bill using the following formula:
Total Sum Approved = Total Sum Claimed X (Room-rent Approved / Room-rent Claimed)
For example, if your room-rent limit is Rs 5000 per day, and you choose a room that costs Rs 10,000 per day, then
Your Sum Approved = Sum Claimed (5000/10000) = 0.5 X Sum Claimed.
That is, only half your claim will be paid, provided that’s still less than your total sum insured.
To avoid this hefty bill to be paid from your pocket always be aware of your room-rent limits, and as far as possible pick a room that falls within the cost/ category.
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For any kind of query you can contact us at Shri Ashutosh Securities Pvt Ltd., we are here to help you in any way possible.
Happy Investing!
(Mutual Fund investments are subject to market risk Illustrations are for example only, there is no guarantee of returns. Past performance is not an indicator/guarantee to future returns).