Health Insurance: All you need to know to avoid rejection of claims

Dr Pankaj Shahane, Vice President – Health Claims, Digit Insurance tells B Krishna Mohan about the pain points in reimbursements and how to deal with them.

Hyderabad: Sometimes it is inevitable to choose a hospital that is not among the network of hospitals of the insurer offering the health policy. Dr Pankaj Shahane, Vice President – Health Claims, Digit Insurance tells B Krishna Mohan about the pain points in reimbursements and how to deal with them.

Reimbursement

When a policyholder receives treatment in a non-network hospital, they will have to bear the entire treatment cost out of their pocket. These costs are subsequently reimbursed by the insurer. One should submit the treatment-related documents to the insurance provider within 15 days of discharge.

Documents

The reimbursement claim process can turn taxing if the policy holders are not aware of the procedures or have not filed all the documents necessary. These include original documents, a signed claim form, hospital discharge summary, medical reports, hospital bill and payment receipts, and pharmacy bills, among others. Some may also ask consultation papers and images of investigation procedures.

Pain points

Claims processing varies with insurers. Settlement of reimbursement claims might take more time than cashless claims due to the insistence of documental proofs. The additional paperwork can sometimes delay the claims process. Claims Settlement Ratio of an insurance company is a metric that one should pay attention to before taking a policy.

Payable limits

For cashless claims, policyholders need to intimate the insurer or the third party administrators at the hospital. The insurers directly settle the claims with the hospitals with minimal documentation. The insurer communicates the amount approved to the hospital. Patient payable amount, if any, is also communicated to the insured. Whether it is a cashless or a reimbursement, only the claim admissible by the insurer will be paid. For example, if a health insurance has a sum insured of Rs 5 lakh and the hospital bill is Rs 7 lakh, the insurer will only pay up to Rs 5 lakh.

Rejection

Policyholders sometimes assume that all medical expenses will be covered. Most policies come with certain exclusions, waiting period, co-payment, and different capping. Also, some require the claims to be filed in a set time period. Understanding the policy terms will help. Claims may also be rejected in case of inflated bills.

Inaccuracy

A cashless pre-authorisation may be rejected by insurers if the underlying condition prima facie appears to be due to a pre-existing condition, where the waiting period is still in force or for any treatments that are part of the exclusions. Hiding pre-existing conditions or medical history could be grounds for claim rejection.