Your Ultimate Guide to Health Insurance Claim

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Fighting an unexpected medical emergency? In  this need of hour, your health insurance policy serves as heroic rescuer. But what if your claim gets denied? Your pre-existing traumatic situation becomes even more distressing.

Which is why, we came up with the ultimate guide to health insurance claim, which will give you all the information you need to overcome any and all obstacles you may face in the claim process. Before navigating you through the process, let us begin by giving you a wholistic understanding of the different types of health insurance policies

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1. Corporate Policy
A corporate insurance policy is a group plan, generally purchased by employers to provide healthcare benefits to the employees of the respective corporate.

2. Retail Insurance Policy
Retail insurance policies is an individual plan, purchased by individuals to design a plan for health coverage.

How Lack of Information Regarding the Claim Process Can Hurt You

Factually, about 85% of policyholders feel they are entitled to receiving every health expense from their insurance company. This sector of people, only need a YES/NO from their insurer company. When the insurer company says yes, they simply assume that any and all expenses incurred will be reimbursed and they rarely bother to enquire.

On the contrary, only 10 to 15% of policyholders actually want to know how much their insurance policy will pay. Although this number is also limited.

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Looking at the larger picture, we can conclude that lack of knowledge and information leads to painful outcomes such as claim rejection.

People 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 most policy holders fail to understand is that the policy coverage is an umbrella that includes a lot of variables – co-pay, deductions, room rent capping, sub-limits, waiting period, and more.

Let us explain to you the scenarios in which the Health Insurance Claim can be made

You can lodge a claim for both pre-planned and unplanned medical emergencies, if you fall in these two scenarios-

  • Minimum requirement of 24 hours hospitalization:- The patient must be admitted for at least 24 hours minimum and the need for hospitalisation is established by a doctor.
  • Check for Day-care procedures in your insurance policy document:- Owning to the advancements in the field of medicine, many surgeries can now be completed within a few hours or some, even shorter. These short-term medical procedures like cataract, chemotherapy, angiography, and radiotherapy are known as day care procedures. However, we highly recommend to check the list of day care procedures mentioned in your policy documents before filing a claim.

Here are some enlisted scenarios in which you can not make Health Insurance Claim

Your health insurance can get rejected in the following scenarios-

  • If the tests are solely conducted for investigation purpose
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Investigation tests are not covered by insurance companies, if the tests outcomes are not leading to any treatment. If no clinically significant issue is detected yet the doctor recommends a line of treatment, claim will be rejected.            

  • The hospitalisation is less than 24 hours or if the line of treatment is not covered in the policy documents

As previously mentioned, 24 hour hospitalization is a minimum requirement for a claim to be addressed. Similarly, if the line of treatment or any medical procedure is not covered under the policy terms, then the claim is inadmissible.

  • If the claim is filed for a medical procedure that falls under the waiting period

Health insurance policies cover certain pre-existing illnesses and illnesses that have a high occurrence rate only after a waiting period of three to four years. So, if your treatment falls under the waiting period, then your claim is inadmissible at the time.

  • If you file a claim for a treatment that is covered but your health insurance policy is not active

Only if the given policy is active, the insurance company will the address claim. Therefore, it is highly important to renew your health insurance policy before it expires or within the grace period of 15 days if you want to enjoy benefits of your policy.

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If you’re having any kind of issue regarding Health Insurance Claim please reach us out below given details.

To reach us at InsuranceSamadhan.com –

Call us at – 844 844 0626

Mail us at – corporate@insurancesamadhan.com

Register your insurance complaint here

Pragya Arora

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