Hidden truths about Health Insurance claims!

Startling growth in healthcare costs today have compelled thousands of us to opt for suitable health insurance cover plans. However, though most of us have health insurance plans to back our hard times up, many amongst us are still not conversant with the nitty-gritties of claiming on the policy, in cases when it is required.

The claim experience is one of the biggest moments of truth for the policy holders, which is why considering the claim settlement ratio of a company is of utmost importance when purchasing a health insurance policy. However, no matter how careful you are in buying a policy, there can always be hidden truths about a health insurance policy claim.

Here, we have listed down the most common ‘hidden’ truths that define health insurance claims –

This might sound shocking, but it’s true that even 100% coverage insurance can have some exclusions, deductibles and co-pays that aren’t paid for under the plan. Plans with lower premiums typically carry higher deductibles, which are supposed to be paid by you out of your own pocket. However, having a health insurance policy in place can lower your expenses even when you have to pay to meet your deductible. Therefore, when choosing a health insurance plan, considering deductibles, co-payments and co-insurance are as important as considering premiums.

Most people tend to think that because they took time to ensure that their hospital was listed under the policy network, they have access to the complete staff at the hospital. However, it’s not always that simple. There may be individual providers, tests, labs or specialists that may work within the facility but still be out of the ‘network’. It can be tedious but it’s important that you ask every single service and person that work with you if they are covered by your insurance policy.

There are certain parameters which must be maintained by a hospital to be able to stick on to a network hospitals list of various insurance providers. There may be hospitals that fail to avoid being blacklisted, which is why Health Insurance companies change their Network List of Hospitals from time to time (which can also happen during your policy term), and uploads new lists on a monthly basis on their official website. On the other hand, even hospitals may refuse cashlessclaims for some insurance companies if they are no longer a network hospital.

The turnaround time for the reimbursement or payment of an insured patient’s treatment costs in a network hospital is generally 20 days for most policies which provide cashless treatment. However, under several circumstances and individual company policies, the payment can be delayed.

For instance, the logistics involved in managing hefty number claims and hospital formalities may result in the TPA (Third Party Administrators that processes insurance claims on behalf of a company) failing to meet the assured deadline even when the insurance company has made the payment. There may also be instances when some TPAs don’t work on Saturdays, which can again create disparity in the process format of the claims.

Depending on the state you are in, the condition of the patient and other factors, you could be eligible for a little more or lesser benefits than your plan tells you about. The best step to take in this regard is to contact your insurance company for a clear understanding of the coverage before getting a treatment done.

Filing a claim can be an overwhelming process, but that should not stop you from buying a health insurance policy. A health insurance cover is vital for the safety of you and your family, to shield you against financial misfortunes in times of need. What you must do instead is assess your health insurance policy on the aforesaid factors, so that your claim requests aren’t marred by any of these.