Health claims are denied, too

MUMBAI: Healthcare seems to have suddenly caught the fancy of life insurance companies. While general insurance companies have long been offering such products, life insurance firms have started entering this space only recently.

Be it a lump sum amount on hospitalisation or ambulance expense reimbursements, the benefits offered under such policies have shot through the roof. Some even claim to cover more than 1,000 illnesses under one policy.

However, lucrative as these covers would appear, one must yet exercise caution before committing himself to any of these policies, lest he run up a lengthy bill only to find his claim denied.

Indeed, while the billboards merrily proclaim that no medical tests are required for taking the health policy, there are bound to be terms and conditions. One might be required to give a self-declaration that he is healthy, unless, of course, he has another policy with the same firm for which he had undertaken a medical examination earlier.

Even though most policies offer the basic benefit of reimbursement of hospitalisation charges, there is a minimum period for which the policyholder needs to be hospitalised.

Usually, insurers ask for a minimum of 24 hours’ hospitalisation. A few others, though, put out additional conditions. A life insurance health product insists on the policyholder being hospitalised for at least two consecutive nights and be charged room rent for at least two days for a claim to be made.

There is also a survival period for the patient, which distributors say is used as an excuse frequently by insurers to deny claims. This basically specifies the minimum period for which the policyholder must be alive for the claims to be payable. The survival period asked by companies ranges between 30 and 60 days.

So, if a survival period of 30 days is specified in the policy and the policy holder dies on the 29th day, none of the medical expenses will be reimbursed.

A few health insurance policies offer post-hospitalisation benefits as well, which is meant for the treatment and care needed after the hospitalisation period, essentially medicines, etc. But, companies specify a condition for this as well. For example, a recently launched policy states that the benefits provided for follow-up tests and post-hospitalisation consultation would be given only if the person has been hospitalised for at least five days.

The same policy puts another condition on claims for surgery. If more than one surgery is conducted under a single anaesthesia, the claim for the severest surgery is paid in full, while only 50% benefit is given for the second surgery. No claim would be paid for any subsequent surgery under the same anaesthesia.

The procedure for submission of bills for claims can be another area that one must pay attention to. Most policies ask for original bills and hospital documents for claims purposes.

So, the policyholder might face a problem if he wants to apply for claims to two different health insurance companies. Check with the insurance firm whether duplicate or attested photocopies of bills are acceptable.

Agreed that when a person in the family is ill, one usually forgets everything else, but do not forget to submit the claims for the health policy within the specified days. Most policies ask for claims documents to be submitted within 60 days of hospitalisation.

To ensure that the medicines have been bought by the patient only on recommendation of a physician, a few insurance companies have even started insisting on prenoscriptions, while accepting bills for the medicines.

In case of critical illness policies, there are several conditions put out on what type of a disease would be covered and what not. For example, while cancer is listed in nearly all critical illnesses lists, certain types of cancers are not included.

These details can be found in the policy wordings that insurance companies offer. One can ask for these and go though the exclusions to avoid getting a shock if his claim is denied later.