A layman guide to health insurance-india- Part II


Most health insurance companies are using the services of TPA (Third party administrators) for collection of documents and settlement of claims. For those purchasing health insurance policies are to be careful in some of the aspects listed below so that their claim is settled in time and without any dispute:

  1. Insured person should ensure that he intimate the      insurer or the TPA about pre-authorization for cashless facility. One  should not leave this to hospital even though it is listed. Of course it is the duty of the hospital to complete the process and forward the pre-authorization form to the insurer on insured person behalf.
  2. Insured person can get his claim settled only when the insured person is hospitalized for 24 hours or more. But this is not applicable to day care procedures like radiation, chemotherapy etc. as covered by the policy.
  3. Pre-existing diseases are not covered generally for first 2- 4 years. So check this while taking the policy. Also some exclusion  will be there like dental, cataract etc. So one should read carefully before choosing a policy under health. He should prefer one with many  advantages.
  4. We should read the fine prints of the policy to know  about expenses that are not covered by the policy.
  5. Also we should check the limits and sub-limits under  each category of expenses like room rent, operation charges, intensive  unit care charges, % of co-payment charges to be paid by the insured.
  6. In case of reimbursement claims, we should inform  insurer/TPA immediately or at least within seven days of hospitalization.  The deadline for the submission of bills along with claim is normally 14  to 30 days.
  7. The insurer/TPA may demand original bills for  reimbursement. But it is not necessary to give any original medical reports like pathological tests, x-rays, ECG etc. Copies can be given if  asked.
  8. If we are not satisfied with services of insurance  company, we can switch to other health insurance companies as health insurance portability has come into effect already.
  9. Some of the common grounds for rejection of claims   are

a) Delay in intimation

b) Delay in submission of original/copies of documents.

c) Inadequate documentations.

d) Claiming for pre-existing diseases during the cool off period of 2-4 years of start of the policy( only as per policy)

f) Claim is for diseases which are excluded under exclusions.

g) Fraudulent claims.

So before choosing the policy, check the company which is issuing policy whether it is a good management or not. Also see the comparative advantages between health policies of different companies  and take time to read the main items as mentioned above .

C.R. Venkata Ramani

(AICWA)

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