Must Follow Health Insurance Guidelines Or Regret Policyholders

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Worst nigthmare for someone who has been paying his/her premiums timely is definitely when he/she receives following message from the insurer's side "We're sorry to inform you that we will not be able to honor your claim because 'dash dash' reason." Health insurance is designed to provide financial assistance in medical emergencies. But it has been seen that some policyholders face health insurance claim rejection due to certain reasons. As I mentioned, nothing would be disappointing than this. Here in this post, I will take you through some important health insurance claim tips that will certainly help you get hassle-free speedy settlement, just in case.

After all, this is why you bought a health insurance, don't you?

Important message I would like to convey right now to you is please read your health insurance policy documents thoroughly because it is immensely important. Majority of policyholders just assume that their policy covers every illness. But it is not true. Your insurer is there to do business, not charity.

Unexpected medical emergencies may occur at anytime. Therefore, everyone should be prepared to cope with such situations physically, mentally and financially. Having a health insurance plan gives us peace of mind that we are financially ready to cope with unexpected medical emergencies.

Health Insurance Claim Tips

It is like a nightmare when a person applies for mediclaim and his insurance company rejects his claim for some reasons. Nowadays, due to stringent guidelines, no company dares to deny a claim request unreasonably. Claim will be rejected only if insurance company has a valid reason.

If claim request has been rejected by the insurer arbitrarily then the policyholder has many ways to force the company to honor his claim.

Points I am going to mention here would seem very obvious but many of them are the most common reasons of a claim refusal. So pay attention to each and every point carefully to prevent health insurance claim rejection.

For your information, this post is part of a series related to health insurance claim. In this series, we have covered topics related to health insurance claim settlements:

  • Useful health insurance claim tips (You are here)
  • How to submit a health insurance claim
  • What to do if the insurance company denies claim request

If you're going to file mediclaim or have a health insurance plan then this post is a must read to make sure your policy will serve its purpose when needed.

Listed health insurance claim tips will help you make successful claim.

As you may already know a health insurance plan has two types of facilities: cashless and reimbursement.

In a cashless health facility, policyholder can avail the treatment free of cost (the cost of the treatment is paid by the Health Insurance Company) in empaneled hospitals.

On the other hand, in the reimbursement plan, policyholder has to pay for the treatment of hospital expenses from his own pocket and later on he can file health insurance reimbursement claim by showing the original hospital bills, receipts , test reports and the like.

If a person avails treatment in an empaneled hospital, he hardly faces any problem in making mediclaim request because all he needs to do is show his medical insurance identity card issued by the insurer.

But if patient is hospitalized in a non-empaneled hospital then insured will be required to present original bill receipts at the time of making claim request.

So first important health insurance claim tip for you is always try to avail treatment in empaneled hospital or if it's not possible in emergency situation then collect all bill receipts, reports and the like.

Health insurance claim tips

Disclose all the facts at the time of purchasing health insurance

Some policyholders face claim rejection just because they had not disclosed the facts clearly at the time of purchasing health plan. Insurance works on the principle of trust. Both parties (the insured and the insurer) have to clearly disclose all the facts.

It is very important that the policyholder fills out the proposal form himself and disclose all the facts asked in it such as facts like whether I drink alcohol or not, whether I smoke or not, whether I have a disease or not.

If the policyholder does not present such facts in the proposal form correctly and later the insurance company finds that the facts were not disclosed properly while purchasing the insurance, then the company may refuse to give the health insurance claim.

In that case, the policyholder cannot appeal to any insurance regulatory authority because he (policyholder) has violated the contract's terms and conditions.

So here if you are going to buy health insurance, then fill the proposal form yourself. Do not let your insurance agent fill it and disclose all the facts.

Read your policy properly

It is often seen that most of the policyholders don't understand their policy wordings and they just assume everything is covered; especially if one has comprehensive health cover. For your knowledge, there is not a single policy on this planet that provides coverage for all risks, be it comprehensive cover or other.

All policies come with exclusions and waiting period for critical illnesses (usually 2-4 years).

Therefore, don't blindly trust your health insurance agent read your policy documents before you pay your premium.

Not to mention, insurance is a legal contract in which there is no value of verbal commitments and assumptions.

Just in case, which probably is, if you already have purchased health insurance cover but yet to read your policy then it'd be in your priority list.

After reading the documents if you find that policy is not meeting your health insurance needs then take advantage of 14 days cooling-off period and get your refund. Or if the mentioned period is expired then you can contact your insurer and upgrade/downgrade your insurance plan.

Avail treatment in empaneled hospital

Policyholder should download a list of network of hospitals with cashless treatment facility from the insurer's website or ask the insurer to provide it. Treatment should always be availed in an empaneled hospital.

The biggest advantage of getting treatment in a hospital recognized by the insurance company is that insured doesn't face any claim related issue and doesn't need to present original bill receipts.

At the top, policyholder can avail cashless treatment facility (would need to pay part of the hospital expenses if copayment is applicable).

Whenever a medical emergency arises, the highest priority should be get treatment without losing any time. But if empaneled hospital is nearby then one should try to visit that hospital.

At the same time, not to mention, if patient is in critical situation then nearest hospital should be visited.

As mentioned before, health insurance claims are unlikely to be rejected when medical service is accessed in empaneled hospital.

Medical card should always be handy

Health insurer issues an identity card to each and every policyholder. This card can be used to avail free treatment at empaneled hospitals. Therefore, keep your identity card handy all the time in your wallet.

When you're taking patient to the hospital, always carry policy documents to get easy access to cashless medical services.

I understand, it becomes very difficult to think of such things in such a situation, but it's worth the trouble because the empaneled hospital also needs proof to verify that patient indeed has a health insurance policy.

If treatment is being availed from non-network hospital, then the policy document is not required because all the expenses have to be paid by the policyholder. In such a situation, all the original bills and receipts should be collected.

Inform your health insurer

As mentioned earlier, to avail treatment from empaneled hospital all a policyholder needs to do is show his medical card. But if patient is being treated in an out-of-network hospital then guidelines issued by the company for mediclaim should be followed.

For example, within 24-48 hours of being admitted in a non-empaneled hospital, insurance company should be informed. If policyholder fails to do so, insurer may refuse to reimburse the hospital expenses.

In this age of digitization, one can use digital channels for example phone, email, insurer's website or app, to inform the company. Or anyone, on behalf of insured, can visit nearest office of the insurance company to initiate claim request.

It's worth mentioning again that all bills, receipts and test reports in original will be required to make a successful claim.

Mediclaim important points:

  • Keep the policy documents and medical card handy
  • Notify insurance company within 24-48 hours. In the event of non-empaneled hospitalization, inform the insurance company as soon as possible.
  • In case of treatment in empaneled hospital, make sure insurer approves your cashless treatment.
  • In case of treatment in non-empaneled hospital, collect all original tax invoices.
  • Try to visit an empaneled hospital.
  • Although in the event of an emergency, one should move to the nearest hospital but it is always beneficial to avail treatment from a network hospital. If the policyholder needs to be admitted to the hospital but there is no emergency then never visit non-network hospital.
  • Remember that some health insurance plans do not offer reimbursement options. So before availing medical services from unlisted hospitals, check whether your Mediclaim policy provides reimbursement, in that case.

If the health insurance policy does not provide any compensation in case of treatment in a non-empaneled hospital, then in such a situation one should go to a recognized hospital.

Also for your information, if you have such a policy then it is not a good policy. Replace it with a mediclaim policy in which treatment can be availed in any hospital.

Existing health insurance policy can be moved to another company without compromising your current policy benefits.

Keep yourself updated

To keep yourself updated, register for email alerts or SMS notifications. By doing this, you can get the latest updates from your insurer regarding the policy terms and conditions. Insurers update via email or SMS if there are any changes in the policy terms and conditions or a new hospital is added to its list of empaneled hospitals.

Insured is required to renew his health card time to time. Therefore, make sure you timely update the same, if required.

In some health insurance policies, policyholders need to undergo periodic medical checkups. If you are required to do the same, then must follow the guidelines of your insurer to stay compliant with your policy rules.

Renew your policy timely

Make a habit of renewing your policy timely before the expiry date. If possible set auto payments for renewal. For your information, you can also convert your health insurance premium in equated monthly installments.

Add your spouse to your policy

If you have just got married then add your spouse to your existing health insurance policy. It's better than buying a separate policy. To get maternity health insurance cover, your spouse needs to be added to your policy; otherwise, you'll not receive the benefits.

Final Words

In today's uncertain and fast paced world, health insurance is a necessity. But merely having a mediclaim policy is not sufficient, you need to be aware of mentioned things to get the benefits when required. Many a times, some policyholders face claim refusal just because of recklessness. And believe me, nothing is worst than that when you pay your hard earned money and in the end of the day, you face claim denial.

What you're supposed to do is first read what does your policy cover and doesn't cover, and read all the terms and conditions and comply with them to get a speedy health insurance claim settlement.