Taking Cover. Bare it all to your insurer

You have done all the documentation with your medical insurance provider and are now hoping that your treatment claims will be settled in full. However, in such situations, people often end up disappointed. They may get only a portion of the sum assured or, worse, find that the claim has been rejected.

Simple reasons There could be many reasons for the health insurer offering part settlement. One, your policy could stipulate sub-limits under various heads of treatment. Usually, room rent, ambulance charges, doctor fee, and medicines, among others, have upper limits.

Two, there are select ailments, especially pertaining to pre-existing conditions or those relating to senior citizens, where the co-payment clause kicks in, and the insured has to pay 10-50 per cent of the total bill. Three, the hospital where you underwent treatment may not be part of your insurance company’s network.

In that case, you have to pay upfront and then claim reimbursement. Four, all documentation from the hospital may not be in order.

So, all medical records, tests conducted, medication provided, doctor observations and discharge summary must be produced to the insurance company, along with other proof of personal identification for full settlement. Apart from these, there are waiting periods of two or more years for treatment of some diseases such as hernia and cataract. So, if you get treated earlier than the waiting period, your claim will not be entertained.

Also note that you need to inform your insurance company 72 hours ahead of any planned treatment and take prior approval. In the case of emergency treatment, your provider must be kept informed within 24 hours.

Inadequate disclosures While the reasons given above are largely procedural in nature, inadequate disclosures too may land you in trouble.

If you do not come clean on all the health issues that you have, it could hurt later. If it is a family floater policy, then the ailments of all the insured members must be disclosed. Even an unrelated disease, if subsequently traced to a pre-existing ailment, is bound to face rejection of claims. Not disclosing details of your personal habits, such as smoking and consuming alcohol too, can prove injurious to your claims.

If at the time of taking the insurance policy, you were a teetotaller and later took to smoking or consuming alcohol, you still need to inform the medical insurance company of the change in habits. Your premiums would then be suitably increased.

Finally, you also need to disclose if you have another medical insurance policy at the time of taking a new one.

Companies can then split the cost proportionately depending on the hospitalisation charges. Non-disclosure of additional policy can also lead to your claim being rejected.

Way to avoid rejection In the case of planned treatment, ensure that you opt for a hospital that is part of the insurance company’s network. This ensures cashless settlement and minimal hassles.

Two, always disclose pre-existing ailments and personal habits. Three, even if not mandated, opt for a medical test at the time of taking the insurance policy. That will ensure transparency and the premiums would be suitably priced in based on your health condition.

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