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5 checks for a smooth health insurance claim process
Don’t get bogged down by the claim rejection stories that you hear from time to time. Your insurer will not reject a valid claim if you satisfy all the conditions and have documentation to support it. Then why do claims get rejected, you ask? Well, there are conditions to be met and checks to be ensured, and that’s what we are here for. Many times you may not be fully aware of the terms and conditions mentioned in your policy document. And if any condition is unclear, you can call us at or your insurer, for clarification. In this article, let us go through the steps you can take to make sure that your claim settlement is process is smooth.
Let us ask the below questions before or while filing the claim-
Are you under the waiting period?
You do not get to file a claim on the day you buy the policy. For certain conditions like cataract, hernia etc. there is a waiting period which implies that you must wait for the period before filing a claim. Policies have waiting periods for pre-existing diseases, some diseases & surgeries, maternity-related expenses etc. In fact, in the first 30 days, most of them don’t admit any claim other than accidental. For example, if you already have diabetes while buying the policy and the waiting period for a pre-existing disease is 3 years, then you will have to wait for 3 years before filing any diabetes-related claim. Check the list in your policy document.
Were you hospitalised for a minimum of 24 hours?
Most of the policies honour claims only if the hospitalisation was for 24 hours, to begin with. Of course, a few daycare procedures are included. But apart from that, you can’t claim every minor procedure that happens in lesser than 24 hours. These lists of what’s covered and what’s not are clearly mentioned in the policy document.
Have you checked the sub-limits?
Many of your claims are not 100% claimable. For example, if you are opting for a knee replacement surgery, then the health cover may just be capped at Rs 80,000 per knee. Hence, when you file the claim, it will be helpful if you know how much to file rather than filing the whole amount and getting it rejected. Similarly, there can be sub-limits on the kind of room you are hospitalised in. Hypothetically, your health cover may allow on Rs 2000 per day as room rent, and you may have spent Rs 4000. When you decide to do that don’t assume that the insurer will pay the difference. They will need to be informed beforehand.
Did you forget to inform the insurer about a pre-existing condition?
For the want of a lower premium or for the lack of information regarding the complete disclosure, at times you may not inform the insurer about a pre-existing disease. If, for example, you have hypertension and you did not mention it. Later, you got admitted on account of high BP and want to claim it. The insurer will study the reports submitted by the doctor and reject you claim. You must always make full disclosure to the insurer.
Did you check the documents required and file in time?
If you are filing a cashless claim, then most of the documents are submitted to the insurer by the hospital’s insurance desk. Although, you will need to inform the insurer at least 4 days prior to the admission or 24 hours in case of emergency hospitalisation. Now, if you are filing a reimbursement claim, you need to file the claim within 7-10 days of the discharge from the hospital. You can find the list of documents to be presented, here. You can also get in touch with us at Marsh India, in case of hospitalisation and we shall be your SPOCs for the procedure and claims. Always keep your insurance card handy!
Were there any co-payment or deductible clauses in the policy?
Both types of clauses basically mean that a certain % of the claim amount needs to be borne by you. In case of co-payment, the % is fixed. So if you are claiming Rs 50,000 and the co-payment clause is at 10%, then you will have to pay Rs 5,000 with Rs 45,000 as the admissible claim. On the other hand, the deductible amount is fixed. Whether you pay this amount from your pocket or from another medical insurance policy, doesn’t matter. The insurer will only admit a claim after deducting the deductible amount.
Did you forget about the exclusions?
Every medical insurance policy has a list of exclusions- some of them are standard and the rest are subjective to the policies. For example, a dental expenditure is generally excluded from all policies. A claim made for that will be rejected. It is often noticed that the policy documents are filled up with brokers/agents on behalf of the buyer. This results in incomplete information about your own policy. Hence, we strongly advise to go through the document and fill up the details yourself, so that you are in the know.
Bonus tips for claim filing-
- Be extra careful about all the medical documents collected from the hospital, including discharge summary, pharmacy bills, investigation reports etc. Make copies and get them attested while you are still in the hospital.
- Never assume, ask questions. Call us or call the insurer, but if you have any queries prior to the admission in the hospital, it is better to get them sorted.
- Know that many consumables like masks, syringes etc. are not claimable. Don’t claim them.
- You can also file claims through multiple medical insurance policies, for example a portion from your company medical insurance and rest from your personal medical insurance. The thing to keep in mind is transparency between the two claims, the claimed amount should not exceed the actual money spent.
Your claim could also be rejected if your health cover is insufficient and lesser than the claimed amount. So, we highly recommend you checking for adequate coverage of your family and yourself. To enhance your health cover, you can either buy additional cover in the same policy, buy an additional base policy or buy a super top-up policy.
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