Keep claim rejections at bay

Vijay Tambe was pretty confident that a mediclaim from a leading public sector insurance company would fully stand by him in his hour of crisis. But that was until some time back. One night, following a severe chest pain, he had to be rushed to a hospital and was asked to go through a series of medical check-ups, which he promptly did without a grumble.

What Tambe did not realise, however, was there’s more shock in store as several procedures were not covered under the insurance scheme. The company made plain that it can not pay up for his several medical tests and ultimately, Tambe had to shell out Rs58,000 from his own pocket. Many of the tests, the company said, were simply unnecessary.

The patient finds himself at the receiving end once private hospitals come to know he has a medical cover in place and is asked to go through a series of tests that face rejection later at the hands of the insurer. In other words, an insurance may not be exhaustive in scope, which is why you need to be cautious of the cost incurred and steer clear of a trap for any superfluous expenditure.

The premium remains an issue. The higher the claim, the bigger the loading. Loading is referred to an increase in the premium charged when you file a claim. To add insult to the injury, insurance companies are known for charging high premiums when claims are made. So, the best course is to keep your claim amount less so that you can enjoy the same premium.

Experts also call for more vigilance insofar as the medical bill goes. One must do a due diligence before signing the bill, they say,  even if there’s a provision for cashless settlement and that the insurance company is footing the bill. This will ensure the document is not tampered with after you leave the hospital.

“If it is a pre-planned check-up, then it is better to notify the third party administrator (TPA) and take necessary approval. By this, you will know what check-ups are going to get covered and what are not. Not just this, you will also have a better idea about the total cost you may have to run up. So, this rules out chances of hospitals making any future changes to the bill,” says Amarnath Anathanarayanan, CEO, Bharti Axa General Insurance.

Sub-limit is another tricky part to look into. “Several policies have sub limits and these are present mostly in room rents. The policyholder should scrutinise the sub-limits carefully to make sure the claim does not get rejected later,” suggests a spokesperson of another health insurance company.

When it comes to choosing hospitals, the safest line is to go with the one that is registered with the TPA unless you are forced to look the other way. Also, it’s foolhardy to expect the insurer to pick up the tab for any sundry bill that may come under the category of comfort or luxury, which includes items such as food, fruit, juices and so on.

A careful look at the exclusion list that outlines the no-go areas will keep you in good stead too. All pre-existing diseases, for that matter, are not covered for a specific period of time.

A claim settlement for health insurance generally does not go beyond a month. But even after taking all necessary steps, if it so happens that your claim is rejected, sweat not. Instead of giving up, you can file a complaint with the insurance company concerned. Make sure the complaint is put in black and white either through a letter or an e-mail so that you can fall back on it as a solid evidence in future. You can move to the next stage by insisting on a written explanation from the insurance company detailing the reasons of a rejection, if any. If the matter still persists, you still have a few more options left, like approaching the insurance watchdog or consumer courts as the final forum. It may be noted that the regulator, Insurance Regulatory and Development Authority (Irda) has taken a series of measures to this effect to alleviate the sufferings. The grievance redressal cell is one of them. One can simply dial 155255 or dash off a mail to complaints@irda.gov.in and expect a quick response from Irda.