You have paid all your health insurance premiums on time thinking your policy will help you in the hour of need. So when you are battling an unexpected medical contingency, using your health insurance policy is the first thing on your mind. But if your claim is denied, your already stressful situation becomes all the more traumatic.

This health insurance claim guide will give you all the information you need to overcome all the hassles and stress that crop up when you are navigating through the claim process. So, let’s start by getting a better understanding of the different types of health insurance plans that an individual has before getting into the claim process.

A corporate insurance policy is designed to provide health coverage to employees. Corporate policies are generally purchased by employers to provide health insurance benefits to their employees.

Retail insurance policies are individual plans purchased by people to create health cover. A retail insurance policy will ensure that you have additional cover as you continue to switch jobs and provide financial security in case you exhaust the cover in your corporate policy.

Let us assume that you have two health insurance policies – a corporate policy with a sum insured of Rs. 2 lakh and a retail policy with a sum insured of Rs. 3 lakh. Now if you face a medical emergency and your medical bill at the time of discharge is Rs. 3.5 lakh, you can use your retail policy with a sum insured of Rs. 3 lakh and use the corporate policy to pay the difference amount of Rs. 50,000.

How Lack of Information Regarding the Claim Process Can Hurt You

Now let’s imagine a hypothetical situation to understand what actually happens at the hospital. There is a patient who is having certain symptoms and so, he decides to consult a doctor. The doctor will diagnose the symptoms and prescribe medication or recommend the required treatment. A lot of back and forth happens during this time as people also go from their general practitioner to a specialist for a second opinion and while all of this is happening, the patient gets clarity in terms of his/her medical condition.

And if the problem is persistent and cannot be treated with medication, the doctor will suggest an outpatient procedure or a surgery and hospitalisation. Now this is the instant when the patient is in acute need of funds. This need compels the person to think – can my insurance policy be of any help here?

Now there are 2 buckets of people in this case:

  1. 87% of people feel they are entitled to receiving every health expense from their insurance company.
  2. Only 13% of people want to know how much their insurance policy will pay. However, the people in this category are very limited in number.

For most people who fall in the first bucket – they only need a Yes/No from their insurance company. And once they get a yes, they assume that any expenses that are incurred up to the amount covered in their policy are payable by the insurance company. So when the policyholder hears a yes – he/she assumes that the insurance company will take care of all the expenses and rarely bothers to ask how much will be provided.

So we can conclude that people lack knowledge and so they never ask – which treatment will be covered? How much will they receive? What is the waiting period? The only thing that people understand is their insurance policy has a cover of 3 lakh so they have 3 lakh to claim.

What they fail to understand is that coverage has a much wider meaning. The term coverage is an umbrella that includes a lot of variables – co-pay, deductions, room rent capping, sub-limits, waiting period, and more. And these are just a few of the many myths that people have when they are filing a claim.

Scenarios in Which the Health Insurance Claim can be Made

You can claim for your medical expenses under your health insurance policy for both planned and unplanned medical contingencies if you fulfill the following conditions:

  • 24 hours hospitalization is needed
    The patient should be hospitalised for at least 24 hours and the need for hospitalisation should be established by a doctor who is qualified to do the diagnosis.

  • Daycare should be covered in the terms of the insurance policy
    Due to advances in medical technology, several surgeries can now be completed in a few minutes. These short-term hospitalisation procedures like cataract, chemotherapy, angiography, and radiotherapy are known as day care procedures. However, it is important to check the list of day care procedures mentioned in your policy documents before claiming under health insurance.

Scenarios in Which You Cannot Claim

Your health insurance can get rejected in the following situations so it is recommended that you check with a CMS expert if you are filing a claim.

  • The Tests are Conducted only for Investigation Purpose
    Investigation tests are not covered by insurance companies if the tests results are not leading to any treatment that can cure the patient’s medical condition. So if the doctor is unable to detect a clinical issue and recommend an active line of treatment after the test results have arrived, then the claim will be rejected even if the test was prescribed by a qualified doctor.
  • The hospitalisation is less than 24 hours or if the line of treatment does not fall under any of the daycare procedures listed in your policy
    24 hour hospitalization is required for a claim to be admissible. Also, if the line of treatment is not covered under the policy terms as a daycare procedure and if the patient is not hospitalised for more than 24 hours, then the insured cannot file a claim.
  • If the treatment procedure is not covered in the policy documents
    Any medical treatment or surgery conducted for any procedure that is not covered in the policy terms cannot be claimed.
  • If the claim is filed for a procedure that is listed in the waiting period
    Health insurance policies cover certain pre-existing diseases and diseases that have a high occurrence rate only after a waiting period of three or four years. So if the waiting period is still applicable on your treatment, then you cannot file a claim.
  • If you file a claim for a treatment that is covered but your health insurance policy is not active
    The insurance company will only settle claims when the policy is active. So it is very important to renew your health insurance policy before it expires or within the grace period of 15 days if you want to enjoy continuity benefits from your policy.

Myths Associated with Medical Claims

Due to lack of consumer education, several myths associated with medical claims deter the insured from taking an informed decision. Some of these common myths include:

The treatments taken at a non-network hospital cannot be claimed.It can be claimed via reimbursement process.
If the claim has been rejected once, the decision cannot be contested.A rejected claim can be contested if you can convince the insurance company that your claim is genuine.
The claim settlement process is always fair.The claim settlement process may not always be fair due to which the insured does not always receive the maximum payout.
The insurance company is liable to pay for all the treatments.The insurance company is only liable to pay for the treatments covered in your insurance policy.
OPD expenses are not covered under a health insurance policy.Certain OPD expenses are covered in the health insurance policy so it is important to refer to the policy documents carefully.
The insured needs to pay the difference of room rent in the medical claim.The insured needs to pay the room rent according to the proportionate deduction applicable in the policy.