Not Getting Full Medical Claims – Here Is Why

We always presume that our insurer is going to fight on our behalf for the best prices when we get admitted to a hospital as patients. After getting discharge from the hospital or at the end of the treatment usually a claim is placed before the health insurer. Sometimes we get shocked to find what we get in the end and it gives feel of a legal battle, settling the claims. What we expect and what we get depends upon a number of reasons. Once we pay the premium, we think we need not worry at all. That is not the case.  Saving our money is not insurer’s motto. There are strong reasons behind it.

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Not all the expenses are covered by the Health plans. Ambulance charges, registration and discharge charges, toiletries are a few examples which are not included for coverage. We need to read all the conditions before we take any health plans. If the hospitalisation is not recommended by a qualified doctor, chances are high that the claim will go unfulfilled. Many health plans exclude maternity, abuse of intoxicants like alcohol and participation in adventure or sports activities. 

There are sub limits attached to the claim. Not everything is paid fully. Despite of a 100% coverage, the payment that one gets from the insurer is quite less. A few treatments and procedures are not paid fully like cataract surgery and kneecap replacement. There is a cap on how much could be paid for an illness. Room rent too sometimes does not get paid fully due to the limits placed on them. 

Sometimes the insured chooses to pay a part payment and the rest is taken care of by the health insurer. It is advisable to opt for a hundred percent cover without co pay condition. One needs to have sufficient funds to contribute towards her/his illness in case of co-payment plans.  If one agrees to pay say 25% then 75% of the claim amount is cover provided by the insurer. For all low co-payment plans, the premium shall be higher. Usually, the Co-payment is higher for old age groups.

Health policies have different waiting periods. In a few cases the initial waiting period is separate from the rest due to the nature of the specific illnesses. Standard initial waiting period is 30 days during which claims are not admitted. New policies will take 2-4 years of waiting time. During this period, any claims pertaining to that policy shall not be allowed.

Hospitals these days charge higher room rents. Covid-19 is one such disease needing extra amount to be paid towards isolated treatments. Policy allows only a certain amount towards rent, any amount paid higher than this limit shall not be borne by the insurer. Also, before getting admitted it is necessary to know whether room rent shall be allowed as a part of the claim or not. If not, it can be taken as an add-on coverage.

When the hospitals charge more by way of expenses which are not part of the insurance plan, the amount of claim gets cut.

A minimum 24 hours of hospitalisation is a condition for acceptance of the claim. There are a few day-care treatments which are clearly mentioned in the policy and shall not be admitted unless covered. 

These days both Covid-19 and Non Covid-19 patients face rejection of a large part of their hospitalisation costs due to the above reasons. Covid-19 coverage plans come with a 15-30 day initial waiting period. Sometimes patients take a lot of time to get cured and the cost is too high to be covered by the policy.

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Krishna Rath is a SEBI Registered Investment Adviser, and since 2015 has been educating netizens on investments and insurance. Krishna is a fee only SEBI RIA and is Odisha's first SEBI RIA. With background in IT, Krishna is changing the advisory space with new innovations in AdvisoryTech.

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