Many times, a claim lodged under our health insurance policy is either rejected in toto or settled partially. This demoralises the policyholder who is already worried about his or her health and this sort of rejection creates more stress. It should be noted that the insurance company is supposed to send the details in a tabular form as to what was the claim amount, how much amount is settled or rejected and the reason therefor. Before going into details, let us see the responsibilities of a Mediclaim policyholder.
- Your responsibility starts with disclosing any health-related issues while purchasing a policy. Insurance policies are based on the principle of utmost good faith and if you hide something the insurer will have the right to reject your claim.
- Ensure that the policy is renewed in time without any break. There is a 15-day grace period for renewal (some companies offer longer grace periods) but this period is without any cover. If you miss this grace period also, contact your insurance advisor or the company to know the procedure, but the company may deny renewing lapsed health insurance or may ask for a medical checkup before taking any decision on renewal.
- Disclose any new developments related to health while renewing the policy.
- Ask the company to send the policy directly to you, so that you can read all the terms and conditions, diseases covered and other details within the ‘Policy Return’ period of 15 days.
Now about the rejections and what the policyholder can do in such cases. I repeat that the insurer must provide a written document to explain why the claim was rejected. This explanation contains bifurcation of the amount claimed, viz., room charges, medical expenses, surgery, doctor’s visit, follow-up, etc. Here are some reasons I came across while attending to policyholders’ grievances.
Hospitalization not reported and/or claim not lodged within the prescribed time limit – There is a period within which you have to inform the insurer of hospitalization and thereafter lodge your claim. If you fail to do so your claim can be rejected. If your reasons for delay are genuine, you may write to the company with proof. The company may consider the delay for a genuine reason.
Unregistered health care centre – The hospital or health care centre must be registered with the local authorities, otherwise the claim will be rejected.
Consumables not covered – The cost of consumables like masks, hand gloves, and cotton bandages, is generally not covered.
Charges - Charges like admission, service, registration, etc., are not covered.
Certain lotions, creams, etc. – These costs are not reimbursed. However, if these are specially required for the surgery, please obtain so in writing from the hospital.
Specified limits – A policy document specifies limits for certain charges such as Rs500 for ambulance, Rs1,500 for room, Rs3,000 for ICU, Rs1,000 for doctor’s visit fees, etc. Any charges paid beyond these limits are not covered and the claim is considered only up to the limit. It should be noted that the higher the room charges, the higher the other costs. If we go for upper-class rooms, operation theatre charges, doctor’s visit charges go up. This also happens if we choose to upgrade after getting admitted. Some policies set limits for cataracts, Ayush treatment, home treatment, etc. So, it would be advisable to check the limits and then choose the room type.
Recently Consumer Forum, Vadodara ordered that ‘Insurance firm cannot decide on medical expenses limit.’ It is related to rejection based on ‘unreasonable charges.’ I have covered this point below.
Day-care treatment – Surgeries like cataracts do not require hospitalization, but there are certain limits, for example, surgery for one eye and for both eyes, once in a policy year.
Surgeries/treatments not covered – Surgeries like cosmetic or organ changes are not covered and the claim will be rejected. Generally, naturopathy is not covered.
Waiting period – Though the policy covers various types of diseases, some of them come under the ‘Waiting Period’ which is from 12 months to up to 48 months depending upon the type of surgery. In one case that I attended, it so happened that the claim of uterus surgery (removal) was rejected citing the condition of 24 months waiting period. When I checked the definition, it clearly said that the waiting period would start from the inception of the first policy. The lady had purchased the policy six years ago and was renewing the same without any breaks. After comparing it with an old policy, I observed that the TPA (Third Party Administrator) had got changed and the new TPA considered the waiting period from the date when the policy got transferred to them. In pointing out this fact, not only did the claim got settled, but the insurance company also paid a penalty at the rate of 2% above the bank rate for wrongful rejection of the claim.
(Every Mediclaim policy contains this clause.)
Method of operation – The claim is either rejected or a query is raised stating that the operation could have been carried out by such and such method instead of the one used for the patient. Keep your head cool (I am aware that it is very difficult) and argue that ‘A patient is a layman in this field and would go by the advice of the attending surgeon who is the best person to judge the prevailing condition of the patient and then take a decision about the method to be used.” You have to argue like this.
Illness due to pre-existing diseases – While purchasing a mediclaim policy, we have to answer questions about whether we have any addiction like smoking, alcohol, chewing tobacco, etc. If this is not properly disclosed, a claim for a disease related to such addictions may be rejected. But I have come across a few rejections citing that a particular ailment is because the patient is diabetic or one with high blood pressure, etc., which was not declared in the policy. However, this argument is not always correct, particularly if the disease or ailment is quite old. Please consult the operating surgeon or doctor attending the patient and request him to give a letter explaining the exact reason for the ailment.
Charges are not reasonable – This is the most disputed and disgusting reason given by insurance companies. Some types of operations are pre-planned, like cataracts, kidney, knee replacement, etc. At such time policyholders can check the cost or package in nearby hospitals and try to choose the most affordable. But it also depends upon the severity of the ailment and he may have to approach speciality hospitals. In such cases, the cost of operation can be higher than the normal one. Similarly, if there is an emergency, the patient or his relatives are not expected to study the ‘reasonableness’ of charges and have to admit the patient urgently. As explained above under ‘Method of Operation’ we have to follow the advice of the doctor or surgeon instead of looking into the cost, the method, etc. If this type of rejection is raised, the claimant has to take a firm stand saying that ‘he is not an expert in the medical field and he would follow the advice by the doctor considering the prevailing health conditions of the claimant.’ Hospitals or doctors do give relevant letters if any such rejection is raised. Please read this letter carefully just to see that points raised by the company are specifically answered.
Claims can be registered online or by calling a toll-free number or by visiting the nearest branch of the insurance company. Sometimes some queries are raised by the insurance companies which need not be construed as ‘Rejection.’ A proper reply to these queries is sufficient. Any grievance should first be taken up with the branch and then to the nodal officer of the company. If not satisfied, the issue can be escalated to the Insurance Ombudsman. The details are available at https://www.cioins.co.in/Ombudsman
. If still not satisfied, one may move to the district consumer commission. At both these places, we can plead our case or through a person duly authorized by us for this purpose. Finally, it is my advice to avoid five-star hospitals as far as possible, because it keeps in control the overall cost of the surgery or treatment and improves your chances of getting your claims cleared.