Important Things About Health Insurance Plans That Can Affect A Claim

Health insurance, a type of insurance that covers the cost of medical care, has become an imperative aspect of life today. Just like car insurance, home insurance or any other type of insurance, in health insurance plans, the customer chooses a policy and agrees to pay a certain cost - also known as premium - at regular intervals. In return, the health insurer agrees to pay at least a portion of eligible medical expenses incurred in a year subject to certain conditions. At the time of need, the policyholder needs to put in a formal request to the health insurance company to get the benefits of the policy. This formal request or application is commonly known as claim. The insurance company, thereafter, validates the claim and, once approved, issues payment to the insured or an approved interested party on behalf of the insured.

Types of health insurance claims

A health insurance plan has two types of claim settlement processes: cashless and reimbursement.

Cashless claims: In case of a cashless claim, the insurer settles all the hospitalisation bills and medical expenses with the hospital directly. In other words, the policyholder is not required to first bear the expenses from own pocket until he or she is compensated for the same by the insurer.

Reimbursement claims: In this case, the health insurance claims process starts when a healthcare provider treats a patient and sends a bill of services provided to a designated payer, which is usually a health insurance company. The policyholder has to initially make payments against the medical bills on from own pocket. Once the insured gets treatment, the insurer is then required to submit relevant bills to the insurance company. The company then reimburses the medical costs incurred. One can get reimbursement facility at both network and non-network hospitals.

Here are some of the factors that can impact your claims made against a health insurance plan:

Sum insured: There is a certain insured sum involved when an individual opts for a health insurance policy. Sum insured is the maximum value for a year that the health insurance company can pay as part of an active insurance policy. This means that a claim on a health insurance policy can only be approved if it falls in the sum insured limit. In case the policyholder utilises the entire sum for a particular year, any additional cashless claims for that year get rejected. Therefore, it is always advisable to have a sum insured of a large amount, say experts. However, this would also lead to a higher premium.

Specific coverage: Many health insurance plans available in the market may have a specific coverage and there may be several diseases not covered under the policy. These are clearly mentioned in the policy documents. Before purchasing a health insurance plan, the policyholder must read the fine-print carefully to avoid confusion at the time of filing a claim. Filing a cashless claim for a disease or medical condition not covered under a health insurance plan leads to rejection.

Representation of facts: Representation of facts is another important factor to be considered while filing a claim on a health insurance policy. Coverage is provided on the basis of information submitted by the policyholder on the proposal form; any mismatch between the declaration and the reality during the time of filing claims can lead to rejection. At the time of buying a policy, the policyholder must provide complete and accurate information. He or she must not hide any medical history from the insurer. The name of the patient and doctor should be entered correctly when filing a claim, otherwise it may lead to unnecessary hassles. Also, the documents - such as hospital bills, reports and prescriptions - should have correct information to increase the chances of a quick and hassle-free claim settlement.

Time limit: In a health insurance policy, the policyholder is required to apply for reimbursement within a certain period of time. If the claim is not filed within the specified time, the claim is turned down. To avoid rejection of claim, it is important to submit the claim in time.

Record of documents: At the time of filing a claim, it is also advisable to maintain a record of all the documents: pre- and post-hospitalisation expenses, hospitalisation records, diagnostic tests, discharge summary, investigation reports etc. These documents can be extremely crucial in case the insurer demands any clarifications.

Policy number, contact details of insured, relationship of insured with the person who is hospitalised, name of the hospital, nature of ailment or accident and commencement date of the symptom of ailment, among other details, should also be ready while intimating a claim, say experts. These details assist the insurance companies in processing the claims and help rule out the possibility of fraudulent and false claims for them.

Premium payments: Insurance companies can deny claims in case the responsible party has not paid the monthly premiums. If the policyholder misses even one payment, the insurer can suspend the customer's policy.

A health insurance claim protects an individual from the prospect of large financial burdens resulting from an accident or illness. Hence, the policyholder should have a good understanding of the health insurance policy, ideally from the time of its purchase in order to avert any kind of confusion at the time of filing a claim. With this, the policyholder is also guaranteed of a more secure future both health-wise and money-wise.

Companies such as IFFCO Tokio offer a host of insurance policies. Family Health Protector Policy, Individual Health Protector Policy, Health Protector Plus Policy Coverage are some of the health insurance policies offered by them.