Importance of having a Health Insurance is a well aware factor because a adequate health insurance cover can save your pocket. From last two years Corona virus and its after complications have made most of the person invest in Health Insurance, which is surely a smart and right decision
But there are so many incidences when people complain about their Insurance company’s claim settlement process and find the same very complex and tiresome and this is the only mentality which is making people to think twice before buying any insurance.
If you also think that getting approved your claim from insurance company is a difficult or complex task then this post might help you to get approval of your health policy instantly.
A wise Policy holder always knows about his policy terms and conditions. Also, there is a common claim processing practice that is being followed by most of the insurance companies in India which a policy holder should always be aware of.
As we all know that Insurance policy wordings are bit complex due to some word jargons which a common man find difficult to understand. Here, we are sharing most common deduction made under Health Claim settlement by the insurance providers and how the deduction works to help you to better understand the claim settlement process of Health Insurance policy-
This is a very common deduction which is made by all insurance companies while processing your health claim and it is also well written in your Health policy.
But, while selling the health policy nobody bother to educate the customer about the same . so, being a customer its our right to know the same and here we are trying to explain the same in as easy way as possible to make it understandable.
Commonly, there is a clause in our Health Insurance Policy which says that expenses relating to hospitalization will be considered in proportion to the eligible room rent/ room category as mentioned in policy schedule.
In India, most of the hospitals billing is dependent on room category and most popular room category are – General room, Standard AC Room, Deluxe room, Suite.
Here the name of room category can be different as per hospital standards but basic structure is same where general room is a common ward and single standard AC room which is the most economical of all the accommodations available in that hospital for single occupancy.
And, hospital billing is mostly based on room type only such as doctor visit charges , nursing charges,diagnostic test charges, surgeon or specialist Fees etc are variable and depends only on your opted room category /type .
Let’s understand with example-
Example 1 – A person having a policy of Rs. 5 Lakh got admitted in hospital for treatment of Dengue and eligible room rent under his policy is 1% of Policy Sum Insured which comes in this case is Rs. 5000/-.
He opted a single Standard AC room of Rs. 4500/- as the room charge is under his eligibility and hospital raised a bill of Rs. 1,25,000/- for treatment , so all the expense of hospitalization will be paid in full and without any deduction.
Example 2– If the same person as stated in example 1 , chooses to stay in deluxe room of Rs. 7000/- , here proportionate deduction will come in picture as he chooses the room above his eligibility. If you think that only Rs. 2000/- difference is being paid by the patient and rest of the bill will be settled by insurance company then, you are not calculating it right.
Actually , in this case patient / Policy holder have to bear most of the expense in proportion to eligible room charges . Such as- if per visit doctor fee is Rs. 1200/- and hospital stay duration is 5 days then insurance company will pay only (5000/7000)*1200*5 = Rs. 4285/- and rest will be deducted in name of proportionate deduction and same will be paid from your own pocket.
Now, you can understand how this proportionate deduction clause can impact your approved claim amount.
So, here is what you can do to get your full claim amount approved from insurer-
1. Buy a larger Sum insured value policy. Some insurers pay actual room charges for policy of Rs. 10 lakh or above.
2. You can buy a hospital cash benefit cover with your Health insurance policy where insurance company will pay a per day fixed amount during your hospitalization so you can easily pay your deducted amount.
3. Go for a top up policy plan.
4. If higher sum insured is not under your budget then try to opt your room as per your eligibility or some time twin sharing room accommodation can be an option.
Also, If you are purchasing health plan for the first time after the age of 60 years then most of the companies apply co payment clause where claim amount is shared between policy holder and insurance company in proportion to 20: 80 respectively or as decided by company.
Sometime in absence of documents or bank details our claim reimbursement took a long time . So we are sharing a List of documents that will always be required for quick approval of your reimbursement of Mediclaim, so it for your future reference-
1. Duly completed claim form – you can download it from your insurance company website also or TPA desk at hospital will help you out.
2. Pre admission investigation and treatment papers in original copy
3. Original discharge summary from the hospital
4. Cash receipts from hospitals and chemists
5. Payment receipts and reports for test done
6. Certificate from the attending doctor regarding the diagnosis
7. Copy of PAN and Aadhar Card
8. Cancelled cheque
9. Always provide your active mobile and email contact details
10.If you have history of same ailment, in some cases that might also be required.