WHY HEALTH INSURANCE CLAIMS GET REJECTED
As across the globe in India also the rejection of health insurance claim is one of the biggest reason for people having negative opinion on it. it is a common argument that insurance company rejected the claim or reduced the payable amount by a big percentage and this is the biggest grievance against insurance companies.
Before we blame insurance company, insurance advisor on non payment of claims reported we should understand that There are many inbuilt limitations on payments and coverage’s in Insurance contract which an insured needs to understand and be prepared for these clauses to be active when he or she is hospitalised
PRE-EXISTING DISEASE
In India the standard individual or Family Insurance Contract excludes treatment for all known and unknown pre-existing disease for 48 months in case the policy is renewed regularly but some insurance companies have come out with products where this exclusion period is less than 48 months.
By Pre-existing disease it means that any disease known or unknown that the insured was carrying on the day Insurance Policy was issued.
At the time of admission it is our duty to understand with treating doctor the exact timelines of the inception of disease and should be sure that its a new episode not pre-existing disease carried forward into the in
Specific Waiting Period
The standard health insurance contract excludes the treatment for the some common conditions for 24 months this list includes:
- Stones in biliary and urinary systems
- Lumps / cysts / nodules / polyps / internal tumours
3. Gastric and Duodenal Ulcers 4. Surgery on tonsils / adenoids
4. Osteoarthrosis / Arthritis / Gout / Rheumatism / Spondylosis / Spondylitis / Intervertebral Disc Prolapse
5. Cataract
6. Fissure / Fistula / Haemorrhoids
7. Hernia / Hydrocele
9. Chronic Renal Failure or end stage Renal Failure
10. Sinusitis / Deviated Nasal Septum / Tympanoplasty / Chronic Suppurative Otitis Media
11. Benign Prostatic Hypertrophy
12. Knee/Hip Joint replacement
13. Dilatation and Curettage
14. Varicose veins
15. Dysfunctional Uterine Bleeding / Fibroids / Prolapse Uterus / Endometriosis
16. Diabetes and related complications
17. Hysterectomy for any benign disorder.
An insured is expected to know and discuss these procedures with the treating doctor before getting admitted for treatment.
Permanent Exclusions in Insurance Contract :
Insured is expected to know what are the permanent exclusions in his/her insurance contract some of the permanent exclusion are listed :
a. Treatment for Dental disease
b. Treatment for EYE sight correction
c. Treatment for Psychiatric and Psychosomatic disorders
d. Treatment for Infertility
e. Treatment for Obesity
f. Cosmetic Surgery
g. Hereditary illness
h. congenital Disease
i. Experimental treatment etc etc etc
Limitation on Expenses
Many Health Insurance policies have inbuilt limitation on expenses which can be incurred in ICU, Room occupation and also has limit on Liability which Insurance company will bear expenses for few procedure and disease treatments and balance has to be paid by Insured.
Services which are Paid when Insured is Hospitalized under Health Insurance Policy:
Medical Expenses which are paid For:
(a)Doctors’ fees
(b) Diagnostics Tests
© Medicines, drugs and consumables
(d) Intravenous fluids, blood transfusion, injection administration charges
(e) Operation theatre charges
(f) The cost of prosthetics and other devices or equipment if implanted internally during a Surgical Operation.
(g) Intensive Care Unit charges
Hospital Accommodation charges
As per the limits declared in health Insurance contract.
Pre and Post Hospitalization charges
These are reimbursed as per limit declared in Health Insurance Contract
Domiciliary Treatment charges
Only in condition when it is certified that accommodation( BED) is not available in hospital or patient is not in a condition to be moved to hospital.
Organ Donor Expenses:
Some health insurance contracts cover up to a defined limit the medical expenses incurred by the donor of organ particularly Kidney if he/she fulfill the condition for Live Donor as defined in Transplantation of Organ Act 1994.
Services Excluded :
Many services provided by hospitals like
1. Telephone, television, diet charges, (unless included in room rent) personal attendant or barber or beauty services, baby food, cosmetics, napkins, toiletry items, guest services and similar incidental expenses or services.
2. Private nursing/attendant’s charges incurred during Pre-Hospitalization or Post-Hospitalization.
3. Drugs or treatment not supported by prescription .
4. Any charges incurred to procure any treatment/Illness related documents pertaining to any period of hospitalization/Illness.
5. External and or durable medical/non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc.
6.. Ambulatory devices such as walkers, crutches, belts, collars, caps, splints, slings, braces, stockings of any kind, diabetic foot wear, glucometer /thermometer and similar items and also any medical equipment which is subsequently used at home.
7. Nurses hired in addition to the Hospital’s own staff.
How to File a perfect health insurance claim :
Expenses incurred during inpatient hospitalization can be indemnified in the following two ways.
Cashless and Reimbursement.
In today’s age the best way to avail health insurance claims is the option to avail CASHLESS TREATMENT, under this process the insurance company clarifies the coverage’s and limits on liability of insurance company before or within few hours of getting admission it helps insured to understand his/her eligibility and OOP( out of pocket ) expenses which need to be paid at the time of discharge.
Before filing Reimbursement Claim an insured should be aware of :
a. Currency of the policy or for how long the policy is active
b. Sum Insured
c. All Limitations on room rent and ICU cost.
d. Any limitation on disease treatment costs.
e. if policy is active for less than 48 Months t
1. Pre-existing conditions excluded during the currency of the policy
f. If the policy is active for less than 24 months
1. Treatment excluded during this period.
g. Treatment or conditions which Permanent exclusions under the health insurance contract.
h. Service whose payment are permanent exclusion under the insurance contract.
This will help calculate the correct OOP expenses .
How to file perfect Reimbursement claim?
The following documents should be collected :
i. First Consultation Papers
ii. All diagnostic documents and inpatient papers.
iii. Detailed Discharge Summary.
iv. Receipt of all the payments made.
v. Bills of all the services incurred from Pharmacy, diagnostic , and any other service.
vi. Proof of covered under health insurance the best document for proof is Policy Copy for the current year.
The expenses should be tabulated neatly and correctly and adjusted against the limits to arrive at final figures to be reimbursed
The claim form should be filled clearly with due attestation of treating doctor and hospital and all the documents and bills should be attached against all the expenses heads as declared in claim form.
When a claim form is compete and submitted to TPA or insurance company , a copy of entire documentation should be kept on which receipt should be taken for record of submission and reference for future correspondence if any.
If an insured follows the process chances of claim getting rejected are mitigated to a large extent.
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