Health Insurance Claim Settlement Simplified

Insurance is an assurance given by an insurer to the insured, to help the latter at one’s most needed, financially trying times like a health scare or an accident. Yet when such an event occurs and one’s insurance claim is denied or delayed, it can be a very distressing situation, which compounds an already stressed time. The fact is that the onus of getting a claim honored also lies in the insured’s hands. True that a claim may be denied for various reasons by the insurer, with clearly stated reasons for the denial. Yet there are those precautions which if taken care of can ensure a smooth and hassle free claim settlement.

Furnish Complete Information

Did you know that incomplete information and non-disclosure of facts in the proposal form followed by intentional or unintentional misrepresentation of facts are the most common reasons for claim repudiation or delay in claim settlement? Lata, a diabetic patient when going in for a health insurance policy failed to disclose her pre-existing health condition on the proposal form. Five years later when she developed a medical complication due to high sugar levels and had to be hospitalized, she filed for a claim, which got repudiated. She was in for a surprise when her claim was not honored on the grounds of “non-disclosure” of pre-existing medical condition. So how could a health policy holder make sure that they do not ever face a situation like Lata? Here are a few pointers

1. Read and fill in the complete proposal form. Make sure you disclose all relevant information about your family’s and your health status in the proposal form. Disclosing all information will also ensure that there is no conflict during the claim settlement procedure, especially with respect to any pre-existing ailment. The bottom line is “Honesty at the time for proposal pays”.
2. Also ensure that you provide correct information pertaining to your lifestyle and habits as well. For instance, state the truth about your smoking or drinking habits.
3. In case the proposal form is being filled by your insurance consultant or an agent, make sure you go through the details filled in thoroughly before signing the document. It is always advisable to fill these documents yourself. In case of Lata, she had signed the document without verifying the details filled in by the agent which led to inaccurate information being given as a consequence of which her claim was not honored.
4. Understand your health insurance coverage. This is an extremely important aspect which has been discussed in details below.

Do Not Misrepresent Facts

In India, misrepresentation of facts is another common reason for claims not being honored. Misrepresentation is usually in terms of manipulated information while procuring the policy or submission of fake bills and documents while making a claim. Raju, who suffered from a bad bout of food poisoning was consequently hospitalized for 3 days. When he submitted the claim for reimbursement it was observed that the cost of medication administered to him was much higher than what is usually given to patients suffering from a similar condition. He submitted a total bill of Rs. 50,000, when the average cost of treatment of the condition is not more than Rs. 20,000, keeping in mind the category of hospital he was hospitalized in. Upon scrutinizing the documents, it was discovered that the medicine bills were manipulated and exaggerated to make a taller claim. This lead to the claim being rejected and it also led to his policy being cancelled due to his intent to make a spurious claim leaving him and his family without any health insurance cover. Had he submitted the correct bills, his claims would have been approved. A recent survey done by Accenture in India, revealed that exaggeration of bills was considered a justified act by many in India. This may be due to the fact that most of the people are unaware that this is actually a fraudulent act.The other instances of misrepresentation which have been observed are, when a claimant

1. Claims for an Outpatient department treatment (OPD)as an Inpatient department treatment (IPD)
2. Backdates documents to showcase that the claim they have made is covered under the current policy period.

The next and the most vital aspect – is that of the insured not understanding his/her health cover.

Know your health insurance cover

Your health insurance cover, be it a cover given by your employer or a cover you have taken separately for your family and self, may have various limitations that are important for you to be aware of. These are:

• Sub-limits:

  Some health policies have a sub-limit on certain features like room rents or select treatments. Make sure that you are aware of these sub-limits while making a claim. It is also important that you know what aspects your claim will not cover. Most often, these would be service charges, administration charges, registration charges, all non-medical expenses, private nurse expenses, telephone calls, laundry charges, etc. You can go for an add on cover instead for instance Bajaj Allianz Hospital Cash that will help you recover these miscellaneous expenses.

• Co-payment:

  Some health plans have a co-payment clause wherein the insured shares a certain amount of the claim. This would vary from insurer to insurer, and plan to plan. In order to be aware of what amount would be payable by you, it is a good idea to check about co-payment in advance.

• Waiting period:

  When purchasing health insurance, make sure you are fully aware of the waiting period applicable for certain illnesses. Also, since the waiting period in health insurance may differ from plan to plan and insurer to insurer, it is important to keep a note of these.

• Claim against Day Care Procedures:

  Certain insurers provide policies that also cover Day Care Procedures such as surgery of cataract, chemotherapy/radiotherapy, or minor surgeries involving local anesthesia, you can opt for a day care procedure. You must check the day care treatment list beforehand to know whether the medical procedure required by you is included in the cover. This may be a better option since you would not have to spend the minimum 24 hours in the hospital, as is mandatory for normal health insurance plans. This would also help you save on your hospitalization expenses, hence, conserving the sum insured.

Ensure the claim settlement is smooth

While the basic procedure for claim settlement remains standard, there are some nuances to consider between cashless claims and while getting your medical expenses reimbursed from the insurer. Another important aspect to consider is the mode of claim settlement i.e. through a TPA or in-house. Usually, insurers which deal with hospitals/policyholders directly have a faster turn-around-time for the claim settlement. It is therefore essential for you to consider the given aspects while selecting your health insurer.

Precision of documentation

Proper documentation is one of the ways that can speed up your claim settlement process. As per records, nearly 30% of claims received are delayed due to additional queries in case of cashless, or insufficient documents in case of reimbursement claims. It is, therefore, essential that you submit all necessary documents at the time of filing the claim.

Important documents that you must submit at the time of making a claim would be-

1. It is also imperative to ensure that all original documents are submitted as photocopies are not accepted. If your policy covers pre and post hospitalization expenses, submit the relevant documents such as receipts and bills for medicines, doctor’s consultation charges, and diagnostic tests.
2. An honored claim is the happiest realization of the premiums paid religiously towards your health insurance policy, year on year. Rejection of the same is not only distressing but is also financially demanding at the most desperate times. Be honest with your insurer, keep yourself well informed about you own policy and save yourself from the bitter experience of claim rejection. A little effort to know your own health insurance policy will go a long way in ensuring that your claims are settled most conveniently.

Visit our website and rely on us whenever you think about a health insurance policy. Contributed By: Suresh Sugathan, Head Health Insurance, Bajaj Allianz General Insurance