Ground rules for a hassle free health insurance claim

It is only when the policy holder knows the claims settlement process fully that the benefits of a health insurance policy can be realised

Written by Sanjay Datta | Published:October 10, 2011 2:29 am

With the ever-increasing cost and need of appropriate healthcare,health insurance has become inevitable. One might have taken the most comprehensive health insurance policy which caters to all your requirements in terms of the sum assured,riders,tax saving benefits etc.,but all these become redundant if the claim is not settled easily when required. The primary parameter to judge the efficiency of a health insurance provider is how easy or cumbersome is its claim settlement procedure.

The health insurance company and the customer share equal responsibility to ensure a hassle free settlement of the claim. Claiming health insurance will be seamless if only you remember a few simple golden rules and follow them.

Scan the policy document

It is important to read and understand the terms and conditions of a policy well. The insurance broker should be asked to explain any term that you do not understand. It is important to be clear about the policy one intends to take in order to avoid any hassle or heartburn in the future. One should be also be aware of disease specific waiting periods incorporated in the policy.

Honour the Proposal Form

Proposal form is the most important part of a policy. It is critical that an individual does not make false declarations while taking the policy. The proposal form is the basis of the contract with the insurer. Hence,the insurance companies are unable to honour a claim if it is not made in accordance with agreed terms. Fill the complete form yourself and sign it yourself. Do not leave it upon your agent.

Check for co-payment clause

Co-payment refers to the amount which is partially borne by the insured on lodged claims each time a medical service is accessed. Many policies impose co-payment if treatment is taken in a hospital outside the insurer’s network. It is,therefore,important to know the existence of this clause and to check whether the hospital of your choice is in the network or not. This payment should not come as surprise or disappointment to you.

Check for sub-limit clause

Sub-limit is any limit or restriction put on the sum insured available for the treatment / service / disease covered under the policy. There are a lot of insurance policies which have sub limits or coverage limits. It is important that you check for sub limits in the policy as these restrict the amount of re-imbursement for individual bill items

Submit all documents

The documentation checklist required for health insurance claims usually includes first prescription of the doctor,treatment related documents,investigation reports (X-rays,ECG,lab reports etc.),original medical bills and receipts of the hospital,labs,doctors etc.,besides an admission and discharge summary form from the hospital. In case of an accident-related hospitalization,a copy of the FIR will also be typically required. Original documents are required to be submitted for reimbursement of bills. Photocopies are not valid.

If it still happens

If an insurer repudiates a claim,insist on a repudiation letter that explains the basis on which the claim is repudiated. If you do not agree,the claim can be represented again as per the escalation matrix in the grievance redressal machinery. If you are still not satisfied,you may approach the insurance Ombudsman,whose decision is binding.

A delay in settlement of a health claim is not always the insurer’s fault. These few simple steps on a customer’s part can ensure speedy and timely settlement of a health claim. u

Author is Head-Customer Service,Health & Motor,ICICI Lombard

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