Why insurers may not pay the claims against medical bills in full

NEW DELHI: The fundamental reason to buy a health insurance policy is to avoid hefty medical bills. However, some cost related to medical bills still has to be borne by the policyholder even when carrying a cashless health card and availing services of a network hospital. Let us understand why your claim may get paid partially even if you have a comprehensive health insurance policy.

Ankit Agrawal, CEO and co-founder, InsuranceDekho, said, “This may happen at times when the claim is made for medical expenses that do not constitute a part of the coverage of a health insurance plan. It may also happen if the insurance provider deems the incurred medical expenses as unnecessary for the required treatment of the insured. Insurance companies only settle claims for those expenses which are mentioned under the coverage/inclusions in the policy document shared with the insured at the time of policy purchase."

Most of the time, deductions in claims are due to factors mentioned below:

Non-Medical expenses: Administrative charges, registration charges, surcharges, food apart from patient’s nutrition, consumables, etc., may not be covered under the health policy.

Charges: Investigation charges/expense that is not related to the ailment for which you are getting admitted may not be paid by the insurer. “For instance, if admission is for say pneumonia then MRI of the spine may not be paid since it is not related to the treatment of Pneumonia," said Aatur Thakkar, co-founder and director, Alliance Insurance Brokers.

Room rent eligibility: This is the essential criterion for getting the maximum out of your claim. “Most of the policy have room rent defined, and if one gets himself/herself admitted to a room higher than the eligibility then he/she is bound to have major deduction as expense head like doctor charges, investigation charges, OT charges vary based on the room category you opt," said Thakkar.

Consumables: Most of the health insurance policy typically does not cover the cost of most consumables used to treat diseases in a hospital. Shankar Bali, joint managing director, Vidal Health, said, “The out-of-pocket expenses, which are not considered in the in claims are consumables, medicines (non-ailment) wearables, copayments, or copays. This percentage of the claim amount has to be borne by the policyholder. It may be on medical bills, hospitalisations or senior citizen policies. Deductible amounts range greatly based on coverage, location, and more. Therefore, this is something that the insured ends up paying from his or her pocket."

Hence, one should always read the policy document clearly and clarify the doubts, if any, with the insurance provider/broker to avoid such gaps in understanding at the time of a claim settlement.

Source: Live Mint