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5 unexpected health insurance claim disputes during COVID-19

Many seek hospital beds, solely for quarantining, as soon as they get a COVID-19 positive test. Without treatment, such claims may not be paid

June 29, 2021 / 05:58 PM IST

The health insurance claims journey is at best a tiresome one. There’s worry, anxiety and confusion, and on top of all these, there are process inefficiencies, endless paperwork and claim delays. On the one hand, you’re dealing with an unwell or injured family member, and on the other you have to worry about whether or not your claim will get approved. And even in cases when it does get approved, you remain unsure about what part of it will actually be paid and how much might be deducted.

Such disputes in the claims process can make it all the more frustrating for you, adding agony to an already unpleasant situation. But what can you do?

You could educate yourself about such situations in advance, so you’re better prepared and not taken aback when they arise.

Here’s a quick list of five less-known disputes in the health insurance claims process, and how you should prepare for them.

Room-rent limits and proportionate deductions: I’ve spoken to policyholders who were shocked to see that only a part of their claim was paid, despite having enough sum insured. What did they miss? Room-rent limits and their role in proportionate deductions. Most policies come with a limit on the room-rent amount – usually, 1-2 percent of your total sum insured per day. If you choose a room that is of a higher cost than this limit, you’ll end up with a hefty bill as per the following formula.

Total Sum Approved = Total Sum Claimed X (Room-rent Approved / Room-rent Claimed)

For example, if your room-rent limit is Rs 5000 per day, and you choose a room that costs Rs 10,000 per day,  then

Your Sum Approved = Sum Claimed (5000/10000) = 0.5 X Sum Claimed.

That is, only half your claim will be paid, provided that’s still less than your total sum insured.

To avoid this situation, always be aware of your room-rent limits, and as far as possible pick a room that falls within the cost/ category. If your limits are too low and you prefer a higher cost/category room, be prepared to pay a part of the bill from your savings.

Medically Necessary Hospitalisations: This aspect is something a lot of people get wrong. Health insurance plans only cover you for hospitalisation expenses that are ‘medically necessary’. And the definition of that is as follows.

-The person needs admission to a healthcare facility for medical management

-The treatment involves a necessary level of care, intensity and duration

-The treatment is prescribed by a qualified medical practitioner/ doctor (who is not related to the patient)

-The treatment conforms to accepted professional standards, medical practice internationally, or in India.

If all these conditions are not fulfilled, your claim might get rejected on the grounds that the hospitalisation was not ‘medically necessary’.

So, ensure that your treating doctor recommends the hospitalisation in writing, before you take admission.

Active Line of Treatment: This is an interesting one too. To be eligible for the health insurance cover, the patient will need to get an ‘active line of treatment’ while being admitted at the hospital.

Now, what does that mean? One cannot get an insurance cover if she is admitted only for the purposes of observation, diagnostic tests or monitoring  and not any necessary treatment while there.

This is all the more relevant in today’s times, with several people seeking hospital beds as soon as they get a COVID-19 positive test solely for the purpose of quarantining. If there is no treatment going on while at the hospital, such claims will not be paid by the insurer.

So, ensure that you know what you’re getting admitted for. If you’re worried about a condition and want to get hospitalised just for monitoring (say pain in the chest or breathlessness), and are sent home without treatment, prepare to pay for the admission yourself.

Reasonable & customary clause: With rampant healthcare inflation, and hospitals increasing their rates indiscriminately, this clause helps insurers protect themselves from exorbitant and unreasonable charges. They gauge reasonable charges by comparing the costs levied by similar grade hospitals in the same area, and only pay what they find to be reasonable. This means that the remaining amount will be borne by you, and this could easily take you by surprise.

While you cannot control the costs imposed by hospitals, you can try and be better prepared for the bills you might be charged. So, always assume you’re paying out of your pocket and scrutinize every bill you receive with the same care. Where possible, take an estimate of the hospitalisation costs in advance and compare the costs to a similar grade hospital nearby. If you think that this hospital is charging unreasonable rates, you can

-Prepare to foot the bill, out of pocket (or)

-Shift to another similar quality hospital that charges reasonably

Lazy errors in the proposal form: An insurer approves your health insurance policy largely on the basis of the personal details and medical declarations provided by you. So, if at a later date (probably at the time of a claim), if the insurance company discovers that the information you provided is not accurate or complete, it will have the right to deny your claim. In fact, it might even choose to cancel your policy altogether on the grounds of misrepresentation.

Always ensure that you provide a detailed, accurate and complete medical history to the insurer. Include all the major and minor health issues you’ve had, any injuries you’ve suffered or surgeries you’ve undergone. No detail is unimportant when it comes to health declarations.

Further, it’s easy to assume that these rejections will solely be for ‘major discrepancies’ in medical history. But that’s not always the case. For example, you might choose an incorrect pin-code while filling the proposal form online (maybe your pin code is shown as invalid). Or, your personal details such as birth-date or full name may not match across the proposal and hospital documents. These can be grounds for claim rejection too. So, take your time and fill everything up with utmost care.
Mahavir Chopra is the founder, Beshak.org, a consumer awareness platform for insurance
first published: Jun 15, 2021 10:05 am