How to get the right health policy, hassle-free claim settlement

Most policies have a 1 to 3 year waiting period for pre-existing disease. Claims during this period are often rejected.

Recently, someone who saw a 40 percent jump in his health insurance premium, from Rs 50,000 to Rs 70,000 without a single recent claim, approached me.

The last claim was four years ago. Yet, the company got him to migrate to a new plan, discontinue the old one, and sent the renewal notice too late for him to compare or switch. The newly claimed features were hidden behind vague clauses in fine print, I was told.

This may seem familiar to you, given the current state of affairs. This is a combined result of the cavalier attitude of policyholders, company priority on enterprise over ethics, agent priority on commission over customers, hospital priority on profit over patients, and regulator priority on resistance over resolution.

The truth is that settling claims is still under your control.

Step 1: Understand what you’re really covered for

Policies are filled with jargons, like 'restoration', 'multiplier', 'exclusions', 'reasonable' and 'customary charges'. You must do three things.

●     Ask questions: What is not covered? What is partially covered? What is conditionally covered?
●     Seek illustrations: If you do not understand how a claim would be settled, ask for simple illustrations to understand them under different scenarios.
●     Check exclusions: They include dental, cosmetic surgeries, maternity (in some policies), expenses, etc. Know them before you buy.

Step 2: Buy the right policy

Avoid plans with room rent caps, sub-limits and co-payments

Room rent caps call for sharing the bill despite paying premiums, if your room rent crosses the cap. Sub-limits restrict how much you can claim for a specific disease. Co-payments mean you must bear a part of the claim yourself. They sound harmless until you find yourself footing lakhs from your own pocket despite paying thousands in premiums. Avoid policies with such limitations.

Choose plans with shorter pre-existing disease (PED) waiting period

Pick a plan with the lowest waiting period for pre-existing diseases like diabetes or BP. Some companies even offer Day 1 PED cover. It's a blessing if you have such a PED.

Read the customer information sheet (CIS)

Companies are mandatorily required to provide a single page CIS document that simplifies the policy’s important terms. Check and read it. Don’t rely solely on benefits companies claim.

Use the free-look period wisely

You get 30 days after purchasing the policy to review it. If something feels off, you have the right to return it and get a refund. Use this window to dig deeper into actual policy terms.

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Step 3: Know your migration and porting rights

Companies can discontinue plans but they must offer a migration (different plan with the same company) option. You can also port your policy to another company with existing benefits. In this case, you must apply 45-60 days before renewal date.

Pro tip: Always mark your renewal date. Set a reminder, two months in advance. If your company increases your premium unreasonably, migrate or port.

Step 4: Avoid common errors

The rejected claims data reveals that a majority of the claims get rejected on a few common grounds. Avoid them to settle your claims seamlessly.

●     Non-disclosure of PED
Always disclose your full medical history. It is better to pay a higher premium than to hold a paper policy.

●     Claims during waiting periods
Most policies have a 1-3 year waiting period for PEDs. Claims during this period are often rejected. Be aware of these timelines. Buy a policy with a shorter PED period.

●     Lack of documentation or incorrect bills
Keep all records - prescriptions, test reports, discharge summaries, hospital bills. One missing paper can delay or reject a claim.

●     Choose companies with real-time claim tracking
Digital-friendly companies allow you to upload documents, track status online, and reduce hassles. Ask for this feature from your company.

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Don’t ignore practical issues

Poor customer service
Many companies have slow helplines and undertrained representatives. Choose a company with good customer reviews and active grievance cells.

Premium increase without justification
Some companies increase premiums massively after even one small claim. Compare the increase in line with medical inflation. You may migrate or port out if they remain unreasonable.

All is not unwell

The industry has seen various improvements.
●     Customer Information Sheets (CIS) are now mandatory in every policy.
●     Cashless claims are standardised across the country
●     National Health Claims Exchange (NHCX) is the central gateway for exchanging claim information digitally.
●     Digital tools like real-time claim tracking, AI-assisted approvals, and fewer documents are making things better.

What should you do?

Here is what you should remember.
●     Choose a policy with no room rent caps or sub-limits or co-pay, short PED waiting
●     Disclose your current health and medical history fully
●     Mark your renewal dates, review renewal notices on time
●     File and track your claims and escalate when necessary
●     Migrate or port out when the need arises

You pay premiums from your hard-earned money. When the time for a claim arises, you don’t deserve delay, denial, or disappearance.

The writer is founder of Zenith Finserve

Disclaimer: The views expressed by experts on Moneycontrol are their own and not those of the website or its management. Moneycontrol advises users to check with certified experts before taking any investment decisions.