Working health insurance claims to your benefit

The proof of a working health insurance is when you walk away from medical care with zero out-of-pocket expense. An ideal scenario would be if you can make it a totally cashless claim and a more practical outcome is when only a minor portion of medical consumables is paid by the policyholder.

Procedural correctness to ensure claims being honoured is one part of the exercise. The other is to ensure all existing features of insurance products that are available in the marketplace are aptly utilised by the policyholder. We list the procedural and policy features that improve policyholder outcomes at the claims desk.

Procedural checks

Ensuring a painless claims experience should begin with a large cover and timely premium payment. With low-cost ₹1-crore policies or a top-up/super top-up facility available, ensuring the same should not be a costly affair. A large cover is effective but timely premium payments put the large cover into effect and should not be ignored.

With a sufficient cover, the policyholder can move to hospital/insurer authorisation for the medical care. The choice of the care provider should also be based on hospital network of the insurer, apart from therapy specialisation and doctor recommendation. While most hospitals are covered by insurer networks currently, ensuring the same is essential. Otherwise, for non-network hospitals, a reimbursement would ensue, where the policyholder meets the medical expenses upfront and later claims reimbursement.

For the actual claim processing, insurers insist on a pre-authorisation before one gets admitted, which is obviously applicable for elective surgeries, and not accidents. Pre-authorisation for a planned medical care can be arranged by contacting the insurer and filing the required authorisation form. If a TPA (Third party administrator) can be brought into the loop, the process can be smoothly arranged which then extends to a cashless experience.

On discharge, a cashless claim is processed at the back-end by the hospital and the insurer. A reimbursement discharge, on the other hand, is complicated. Policyholders should clear the bills themselves. On clearance, all the required paperwork should be collected before leaving. This includes the medical paperwork, scans and other lab test results. All bills paid for, in the interim or the exit, which should extend to the pharmacy and the diagnostics, should be collected. Reimbursement claim would involve iterative exchange of ‘complete’ information and policyholder would be advised to plug any gaps in information to reduce the time taken to clear the claim.

Feature bonus

Features or add-ons of insurance policies — including room rent, PED wait times, consumables and OPD allowance — can further smoothen the claims experience, directly or indirectly. Room rent limits of ₹5,000 per day or 1 per cent of sum assured are being done away with in new policies as a base feature. In earlier generation policies, when room chosen was higher than limit, the entire medical bill was inflated proportionally by the insurer.

Assessing PED (pre-existing diseases) wait times is critical for claims to go through smoothly. There are add-ons from HDFC Ergo or Star Health which, for an additional cost of 3-5 per cent, reduce wait times from four years to one or two years.

Medical consumables, especially post-Covid, have made a leading appearance on medical bills, to the extent of 15-20 per cent of the bills. These charges cannot be claimed for payment and have to be met from out-of-pocket, unless a specific add-on is chosen. Consumables add-on, which costs only 4-5 per cent of annual premium, can help policyholder claim a larger portion of the cost from the insurer.

OPD add-ons are the other useful feature, though they are not related to the actual medical care claim. The consultations that are part of the pre and post-hospitalisation up to a limit of 30-60 days are covered in the health insurance, even without an OPD cover. An OPD cover can extend the same feature to a longer period, which may be necessitated by the longer recovery times of some procedures. OPD coverage limits range from ₹1,500 to ₹20,000 per year and cost 7-10 per cent over the annual premium. In case of recuperation from an accident, physiotherapy may also be covered.

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